Provider Demographics
NPI:1952512683
Name:LIESEMER, KATHERINE BIBB (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BIBB
Last Name:LIESEMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:BIBB
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CTR
Mailing Address - Street 2:BLDG 9040 FITZSIMMONS DR
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-5090
Mailing Address - Fax:253-968-1618
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-5090
Practice Address - Fax:253-968-1618
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58945208D00000X
WAMD60277286208000000X, 2080P0203X
UT7030213208000000X
UT7030213-12052080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics