Provider Demographics
NPI:1568485662
Name:GRUSMAN, GAYLE LYNN (APN)
Entity Type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:LYNN
Last Name:GRUSMAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 W HORIZON RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5075
Mailing Address - Country:US
Mailing Address - Phone:702-564-8556
Mailing Address - Fax:702-564-4485
Practice Address - Street 1:2350 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5075
Practice Address - Country:US
Practice Address - Phone:702-564-8556
Practice Address - Fax:702-564-4485
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000826207Q00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505485Medicaid