Provider Demographics
NPI:1609184043
Name:GROSS, AMANDA JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:GROSS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:HORNUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-8000
Mailing Address - Fax:701-364-8078
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30715367500000X
MNR176928-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15472Medicaid
ND15472Medicaid