Provider Demographics
NPI:1821042029
Name:ROLEN, KATRINA A (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:A
Last Name:ROLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0816
Mailing Address - Country:US
Mailing Address - Phone:208-743-2511
Mailing Address - Fax:208-799-5528
Practice Address - Street 1:1250 IDAHO STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-7427
Practice Address - Fax:208-743-7421
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9061207RX0202X
WAMD00043348207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI11381Medicare UPIN