Provider Demographics
NPI:1144420787
Name:LEREW MUSGRAVE, KATJE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:KATJE
Middle Name:MARIE
Last Name:LEREW MUSGRAVE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WESTOVER DR # 16969
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-8941
Mailing Address - Country:US
Mailing Address - Phone:505-470-7498
Mailing Address - Fax:
Practice Address - Street 1:4650 SIGNAL TREE DR UNIT B200
Practice Address - Street 2:
Practice Address - City:TIMNATH
Practice Address - State:CO
Practice Address - Zip Code:80547-4911
Practice Address - Country:US
Practice Address - Phone:970-821-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1644-11207Q00000X
MI5101018928207Q00000X
MET0753207Q00000X
CODR0053047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432680799Medicaid
CO44931549Medicaid
MENONEOtherRESIDENT-NO PROV #
CONMAAA2425OtherMEDICARE ID