Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 52345 | CO |
Y | 207QS0010X | Family Doctor - Sports Medicine | 52345 | CO |
NPI | 1184662272 |
---|---|
Provider Name | Mrs. Kathryn A Vidlock Granley |
First Address | Parker, CO 80134-7507 |
Second Address | Parker, CO 80134-7507 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2006 |
Last Update Date | 12/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G84388 | (02) | MN |