Healthcare Provider Details

I. General information

NPI: 1912142829
Provider Name (Legal Business Name): KATRINA HERVEY GRANT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATRINA MICHELLE HERVEY

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 WYOMING BLVD NE
ALBUQUERQUE NM
87109-3167
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6600
  • Fax: 505-462-6641
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2021-0057
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD29388
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: