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NPI Code Detail

MEDICARE: KELLY THOMAS MSN, AGPCNP-C

MEDICARE: KELLY THOMAS MSN, AGPCNP-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LG0600XGerontology Nurse Practitioner4704259921MI

General Provider Information

NPI Number : 1134761042
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY THOMAS MSN, AGPCNP-C
Provider Business Mailing Address
First Line : 2540 16TH ST
Second Line :
City : PORT HURON
State : MI
Zip : 48060-6405
Country : US
Telephone Number : 810-987-1000
Fax Number :
Provider Business Practice Location Address
First Line : 2540 16TH ST
Second Line :
City : PORT HURON
State : MI
Zip : 48060-6405
Country : US
Telephone Number : 810-987-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2019
Last Update Date : 10/11/2019

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