Provider Demographics
NPI:1487924254
Name:ROBERTS, KATHRYN ANNE (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ANNE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3548
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3548
Mailing Address - Country:US
Mailing Address - Phone:360-428-2550
Mailing Address - Fax:360-428-6402
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274
Practice Address - Country:US
Practice Address - Phone:360-428-2550
Practice Address - Fax:360-428-6402
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 605755332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029144Medicaid