Provider Demographics
NPI:1013919257
Name:AUTREY, KATHRYN M
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:AUTREY
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 1:2520 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4907
Mailing Address - Country:US
Mailing Address - Phone:575-522-9793
Mailing Address - Fax:575-532-9019
Practice Address - Street 1:12174 N MOPAC EXPY STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2910
Practice Address - Country:US
Practice Address - Phone:512-994-2662
Practice Address - Fax:512-406-6202
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM427176B00000X
TXAP129827367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX380935201Medicaid
TX380935202Medicaid
NMT8776Medicaid
NM53483OtherPRES
NMS67306Medicare UPIN