MEDICARE: DR. KATHARINE POLAND DAT, ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT6693	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AT6693	OTHER	TX	TEXAS DEPARTMENT OF LICENSING AND REGISTRATION

General Provider Information

NPI Number	:	1275122582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHARINE POLAND DAT, ATC, LAT

Provider Business Mailing Address
First Line	:	401 E 8TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 E 8TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5504
Country	:	US
Telephone Number	:	469-352-6804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2021
Last Update Date	:	01/12/2021

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