Basic Information
| Provider Information | |||||||||
| NPI: | 1275272650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORTEZ | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | CRNA, DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076072009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019525441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
| FaxNumber: | 6082585222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2022 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6296549 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 13241 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1275272650 | 05 | WI | MEDICAID |