Provider Demographics
NPI:1316180375
Name:ROMAN, KATHLEEN DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:DIANE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:DIANE
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3702 AUTOMATION WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5738
Mailing Address - Country:US
Mailing Address - Phone:970-224-2985
Mailing Address - Fax:970-223-1118
Practice Address - Street 1:3702 AUTOMATION WAY STE 103
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5738
Practice Address - Country:US
Practice Address - Phone:970-224-2985
Practice Address - Fax:970-223-1118
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25994207L00000X
CODR.0047727207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71877525Medicaid
P00748258OtherMEDICARE - RR
P00748258OtherMEDICARE - RR