Provider Demographics
NPI:1467823138
Name:ROUMBANIS, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:ROUMBANIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 1021
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3007
Mailing Address - Country:US
Mailing Address - Phone:707-284-2950
Mailing Address - Fax:707-284-2955
Practice Address - Street 1:2403 PROFESSIONAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3007
Practice Address - Country:US
Practice Address - Phone:707-284-2950
Practice Address - Fax:707-284-2955
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4900009RN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA494907000OtherMEDI-CAL