Healthcare Provider Details

I. General information

NPI: 1174508832
Provider Name (Legal Business Name): KELLY GAYLE THORSTAD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12174 N MO PAC EXPY SUITE A
AUSTIN TX
78758-2910
US

IV. Provider business mailing address

12174 N MO PAC EXPY SUITE A
AUSTIN TX
78758-2910
US

V. Phone/Fax

Practice location:
  • Phone: 512-833-7334
  • Fax: 512-833-7333
Mailing address:
  • Phone: 512-833-7334
  • Fax: 512-833-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL0651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: