Provider Demographics
NPI:1932194875
Name:LEGE, FRED CAMPBELL (ARNP)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:CAMPBELL
Last Name:LEGE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 E VERMIJO AVE STE 16
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2208
Mailing Address - Country:US
Mailing Address - Phone:710-520-7080
Mailing Address - Fax:
Practice Address - Street 1:27 E VERMIJO AVE STE 16
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2208
Practice Address - Country:US
Practice Address - Phone:710-520-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN 181292/5312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9637356Medicaid
P73550Medicare UPIN
WAAB33669Medicare ID - Type Unspecified