Basic Information
| Provider Information | |||||||||
| NPI: | 1548624158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAST | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | GARTLAND | ||||||||
| OtherFirstName: | KELLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 E 104TH ST | ||||||||
| Address2: | MAILSTOP 400S | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169325350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 WORNALL RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169325350 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2016 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 62523 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 0446122 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 2022011330 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.