Provider Demographics
NPI:1396708269
Name:DOMAN, KATHLEEN A (MD)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:DOMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 UNIVERSITY EXEC PARK DR STE 123
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1358
Mailing Address - Country:US
Mailing Address - Phone:704-503-4400
Mailing Address - Fax:704-503-4030
Practice Address - Street 1:8401 UNIVERSITY EXEC PARK DR STE 123
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1358
Practice Address - Country:US
Practice Address - Phone:704-503-4400
Practice Address - Fax:704-503-4030
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39726207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7928814Medicaid
NC7928814Medicaid
NC2155111EMedicare PIN