Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | J7860 | TX |
Y | 208600000X | Surgeon | J7860 | TX |
NPI | 1003900119 |
---|---|
Provider Name | Kelly Eugene Tjelmeland |
First Address | Austin, TX 78731-6026 |
Second Address | Austin, TX 78731-6026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 22/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110753404 | (05) | TX |
8AQ830 | BCBS INDIVIDUAL NUMBER (01) | TX |
G25850 | (02) | TX |