Healthcare Provider Details

I. General information

NPI: 1184614828
Provider Name (Legal Business Name): LORRAINE GWEN GRUBE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 NORTH C STREET
CRIPPLE CREEK CO
80813
US

IV. Provider business mailing address

3205 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917-5101
US

V. Phone/Fax

Practice location:
  • Phone: 719-200-9668
  • Fax:
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1516
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: