Provider Demographics
NPI:1013199579
Name:POLO, KATHLEEN B (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:POLO
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 1:915 6TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4682
Mailing Address - Country:US
Mailing Address - Phone:253-403-7299
Mailing Address - Fax:
Practice Address - Street 1:915 6TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4682
Practice Address - Country:US
Practice Address - Phone:253-403-7299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36931204D00000X
WAMD60221607204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM