Basic Information
| Provider Information | |||||||||
| NPI: | 1124258876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUBRIDY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | EIKO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12721 30TH AVE NE STE 101 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981254498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064170326 | ||||||||
| FaxNumber: | 2064170783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60238358 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0052409 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1124258876 | 05 | WA | MEDICAID |