Provider Demographics
NPI:1750310967
Name:AU HARGRAVES, KATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:AU HARGRAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W 37TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-6964
Mailing Address - Country:US
Mailing Address - Phone:310-283-1343
Mailing Address - Fax:
Practice Address - Street 1:675 E 2100 S STE 390
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-5314
Practice Address - Country:US
Practice Address - Phone:800-366-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91202207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A912020Medicaid
CAWA91202IMedicare PIN
CA00A912022Medicare PIN
I49684Medicare UPIN
CA00A912024Medicare PIN
CAWA91202FMedicare PIN
CA00A912023Medicare PIN
CAWA91202DMedicare PIN
CA00A912020Medicaid
CAWA91202HMedicare PIN
CAWA91202JMedicare PIN