Provider Demographics
NPI:1336107812
Name:KOLLMAR-WADLAND, KATHLEEN (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KOLLMAR-WADLAND
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 EAST FAIRHAVEN AVENUE POB 329
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-0329
Mailing Address - Country:US
Mailing Address - Phone:360-755-0641
Mailing Address - Fax:360-755-1405
Practice Address - Street 1:835 EAST FAIRHAVEN AVENUE POB 329
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-0329
Practice Address - Country:US
Practice Address - Phone:360-755-0641
Practice Address - Fax:360-755-1405
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8855065Medicare ID - Type Unspecified
S81792Medicare UPIN