Provider Demographics
NPI:1982791901
Name:KIRK, KATHERINE A (CRNA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:KIRK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:FAVATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:105 DART CIR
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13441-4229
Mailing Address - Country:US
Mailing Address - Phone:315-533-5747
Mailing Address - Fax:
Practice Address - Street 1:105 DART CIR
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441-4229
Practice Address - Country:US
Practice Address - Phone:315-533-5747
Practice Address - Fax:315-362-5120
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4844631163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB2782Medicare PIN