Provider Demographics
NPI:1912142829
Name:GRANT, KATRINA HERVEY (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:HERVEY
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:MICHELLE
Other - Last Name:HERVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:5550 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3167
Practice Address - Country:US
Practice Address - Phone:505-462-6600
Practice Address - Fax:505-462-6641
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2021-0057207Q00000X
ORMD29388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD29388OtherLICENSE
OR500620343Medicaid
ORMD29388OtherLICENSE