Provider Demographics
NPI:1043985914
Name:REGAN, KATHRYN L (OD, MS)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:L
Last Name:REGAN
Suffix:
Gender:F
Credentials:OD, MS
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 130
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576-0130
Mailing Address - Country:US
Mailing Address - Phone:602-271-7960
Mailing Address - Fax:
Practice Address - Street 1:6000 KANAKANAK ROAD
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576
Practice Address - Country:US
Practice Address - Phone:907-842-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002524152W00000X
COOPT.0003866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOPT-002524OtherAZ STATE LICENSE ISSUED BY BOARD OF OPTOMETRY
COOPT.0003866OtherCO STATE LICENSE ISSUED BY DORA