Provider Demographics
NPI:1275530925
Name:BURGESS, KATHLEEN H (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:BURGESS
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 3129
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98046-3129
Mailing Address - Country:US
Mailing Address - Phone:425-712-3417
Mailing Address - Fax:425-712-3710
Practice Address - Street 1:12824 SE 4TH PL
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3608
Practice Address - Country:US
Practice Address - Phone:425-258-7511
Practice Address - Fax:425-258-7742
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041753208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8449977Medicaid
WA8449977Medicaid
WAI05383Medicare UPIN