Individual
KATRINA HERVEY GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
5550 WYOMING BLVD NE, ALBUQUERQUE, NM 87109-3167
(505) 462-6600
(505) 462-6641
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD2021-0057
NM
207Q00000X
Family Medicine Physician
MD29388
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500620343
—
OR
01
—
MD29388
LICENSE
OR
Enumeration date
12/05/2008
Last updated
11/15/2021
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