Basic Information
| Provider Information | |||||||||
| NPI: | 1467823138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUMBANIS | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 1021 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | 4900009RN | CA | Y | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | 494907000 | 01 | CA | MEDI-CAL | OTHER |