Provider Demographics
NPI:1255616629
Name:DEARBORN, KATHRYN CLARK (CRNA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLARK
Last Name:DEARBORN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 E ELIZABETH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4000
Mailing Address - Country:US
Mailing Address - Phone:970-224-2985
Mailing Address - Fax:970-472-9381
Practice Address - Street 1:2233 STATE ROUTE 86
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:581-891-4141
Practice Address - Fax:404-941-1282
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCRA-100084367500000X
NY615852-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80574823Medicaid
COCOAAA4235OtherCO MEDICARE
COP01080610OtherMEDICARE RAILROAD