Basic Information
| Provider Information | |||||||||
| NPI: | 1396778957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINSTON | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6090 REDWOOD BLVD, SUITE A | ||||||||
| Address2: | MARIN COMMUNITY CLINIC | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052321920 | ||||||||
| FaxNumber: | 5057279276 | ||||||||
| Practice Location | |||||||||
| Address1: | 9101 MONTGOMERY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052754288 | ||||||||
| FaxNumber: | 5052754203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 87167 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 754820 | 05 | NM | MEDICAID |