Provider Demographics
NPI:1942393939
Name:RISSE, KATHY A (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:RISSE
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 1:1100 9TH AVE
Mailing Address - Street 2:MS: M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:2671 NE 46TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5041
Practice Address - Country:US
Practice Address - Phone:206-525-8000
Practice Address - Fax:206-525-8070
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037889208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0039577OtherLABOR AND INDUSTRIES #
WA8291692Medicaid
WA7556RIOtherBLUE SHIELD #
WAUS7586226OtherAETNA SPECIALIST PIN
AKMD0948WMedicaid
WAG8800523Medicare PIN
WAUS7586226OtherAETNA SPECIALIST PIN