Provider Demographics
NPI:1609181353
Name:MCMULLEN, KATHERINE ROBERTS
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROBERTS
Last Name:MCMULLEN
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 1:200 N COMAL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3505
Mailing Address - Country:US
Mailing Address - Phone:210-335-6260
Mailing Address - Fax:210-335-6193
Practice Address - Street 1:200 N COMAL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3505
Practice Address - Country:US
Practice Address - Phone:210-335-6260
Practice Address - Fax:210-335-6193
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX570460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX548941YK00Medicare PIN