Basic Information
| Provider Information | |||||||||
| NPI: | 1841252541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASKO | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CP000463 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 6828360 | 05 | SD | MEDICAID | 01-23603 | 01 | MEDICA SELECTCARE | OTHER | 60832 | 01 | HEALTH PARTNER | OTHER | 975839900 | 05 | MN | MEDICAID | 931451047306 | 01 | PREFERRED ONE | OTHER | 182837 | 01 | UCARE | OTHER | 4994141 | 01 | SD | SD BCBS | OTHER |