Basic Information
Provider Information | |||||||||
NPI: | 1316180375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROMAN | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | DIANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RYAN | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | DIANE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3702 AUTOMATION WAY STE 103 | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805255738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702242985 | ||||||||
FaxNumber: | 9702231118 | ||||||||
Practice Location | |||||||||
Address1: | 3702 AUTOMATION WAY STE 103 | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805255738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702242985 | ||||||||
FaxNumber: | 9702231118 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2009 | ||||||||
LastUpdateDate: | 01/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25994 | NE | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | DR.0047727 | CO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 71877525 | 05 | CO |   | MEDICAID | P00748258 | 01 |   | MEDICARE - RR | OTHER |