Provider Demographics
NPI:1639702772
Name:GRUNERT, MARK THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:GRUNERT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:319 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1742
Practice Address - Country:US
Practice Address - Phone:518-438-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant