Provider Demographics
NPI:1326476466
Name:BEAR CREEK FAMILY MEDICINE, PROF. LLC
Entity Type:Organization
Organization Name:BEAR CREEK FAMILY MEDICINE, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT, CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GRABLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:719-632-0324
Mailing Address - Street 1:2620 TENDERFOOT HILL ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8353
Mailing Address - Country:US
Mailing Address - Phone:719-632-0324
Mailing Address - Fax:719-632-0326
Practice Address - Street 1:2620 TENDERFOOT HILL ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8353
Practice Address - Country:US
Practice Address - Phone:719-632-0324
Practice Address - Fax:719-632-0326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
CO2402363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOAAA2042Medicare UPIN