Healthcare Provider Details

I. General information

NPI: 1952512683
Provider Name (Legal Business Name): KATHERINE BIBB LIESEMER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE BIBB BENTON M.D.

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CTR BLDG 9040 FITZSIMMONS DR
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-5090
  • Fax: 253-968-1618
Mailing address:
  • Phone: 253-968-5090
  • Fax: 253-968-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number58945
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60277286
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7030213
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number7030213-1205
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD60277286
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: