Provider Demographics
NPI:1457393068
Name:GRUGEON, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:GRUGEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RIDGEHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-2372
Mailing Address - Country:US
Mailing Address - Phone:484-356-0353
Mailing Address - Fax:610-692-7838
Practice Address - Street 1:1646 W CHESTER PIKE
Practice Address - Street 2:SUITE 21
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-7995
Practice Address - Country:US
Practice Address - Phone:610-696-0338
Practice Address - Fax:610-692-7838
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006383B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P43515Medicare UPIN
052403M5LMedicare ID - Type Unspecified