Provider Demographics
NPI:1073575460
Name:GROSSO, MEGAN M (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:GROSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:M
Other - Last Name:TURCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-4243
Mailing Address - Fax:315-464-5350
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4243
Practice Address - Fax:315-464-5350
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02877383Medicaid
NY02877383Medicaid