Provider Demographics
NPI:1346209384
Name:NWEKE, GRACE N (MD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:N
Last Name:NWEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4020 PALMER PARK BLVD
Mailing Address - Street 2:SUITE 101-B
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-3433
Mailing Address - Country:US
Mailing Address - Phone:719-577-9977
Mailing Address - Fax:719-577-9911
Practice Address - Street 1:4020 PALMER PARK BLVD
Practice Address - Street 2:SUITE 101-B
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3433
Practice Address - Country:US
Practice Address - Phone:719-577-9977
Practice Address - Fax:719-577-9911
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34753207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804092OtherMEDICARE PTAN
CO01347533Medicaid
CO74575724Medicaid
COG18181Medicare UPIN
CO01347533Medicaid