Provider Demographics
NPI:1003144296
Name:GROTH, LAURIE ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:GROTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S SERVICE RD STE 350
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 620727163W00000X
NY620727367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty