Provider Demographics
NPI:1215932868
Name:MACAULAY, KATHARINE SAN (CRNA)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:SAN
Last Name:MACAULAY
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:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-557-4221
Mailing Address - Fax:719-557-3834
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-557-4221
Practice Address - Fax:719-557-3834
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95070207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07950702Medicaid
R71055Medicare UPIN
CO07950702Medicaid
184718Medicare ID - Type Unspecified