Provider Demographics
NPI:1699711358
Name:MCKENNA, KATHLEEN MOIRA (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MOIRA
Last Name:MCKENNA
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3404
Mailing Address - Fax:
Practice Address - Street 1:100 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3805
Practice Address - Country:US
Practice Address - Phone:650-696-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG673062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G673060Medicaid
CA300121871OtherRAILROAD MEDICARE
CABH532WMedicare PIN
CABH532ZMedicare PIN
CA00G673060Medicaid
CA00G673060Medicare PIN
CA300121871OtherRAILROAD MEDICARE
CAF61738Medicare UPIN