Provider Demographics
NPI:1154677854
Name:GRISALES, DIEGO A (NP)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:A
Last Name:GRISALES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-3632
Mailing Address - Country:US
Mailing Address - Phone:585-545-7200
Mailing Address - Fax:
Practice Address - Street 1:259 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-3632
Practice Address - Country:US
Practice Address - Phone:585-545-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03504529Medicaid