Provider Demographics
NPI:1326075631
Name:GRUCZA, LYNN M (NP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:GRUCZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S ELMWOOD AVE
Mailing Address - Street 2:EHS INC DBA EVERGREEN HEALTH SERVICES
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-2398
Mailing Address - Country:US
Mailing Address - Phone:716-847-0212
Mailing Address - Fax:716-847-2715
Practice Address - Street 1:206 S ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-2398
Practice Address - Country:US
Practice Address - Phone:716-847-0212
Practice Address - Fax:716-847-0418
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300969363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S27232Medicare UPIN
RB0339Medicare ID - Type Unspecified