Basic Information
| Provider Information | |||||||||
| NPI: | 1184614828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUBE | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | GWEN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7193447837 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 NORTH C STREET | ||||||||
| Address2: | |||||||||
| City: | CRIPPLE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192009668 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 12/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1516 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 44985738 | 05 | CO | MEDICAID |