Provider Demographics
NPI:1912378241
Name:ROEDER, KATHLEEN K (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:K
Last Name:ROEDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 HARKLE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4765
Mailing Address - Country:US
Mailing Address - Phone:505-955-9411
Mailing Address - Fax:
Practice Address - Street 1:649 HARKLE RD
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4765
Practice Address - Country:US
Practice Address - Phone:505-955-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2015-0079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant