Provider Demographics
NPI:1427167535
Name:KILLEEN, THOMAS EDWARD (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:KILLEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9770 SOUTH MCCARRAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523
Mailing Address - Country:US
Mailing Address - Phone:775-322-4589
Mailing Address - Fax:775-322-3787
Practice Address - Street 1:9770 SOUTH MCCARRAN BLVD.
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523
Practice Address - Country:US
Practice Address - Phone:775-322-4589
Practice Address - Fax:775-322-3787
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00G03369Medicaid
NV00G03369Medicaid