Provider Demographics
NPI:1740242668
Name:GROSS, EDITH CHRISTINE II
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:CHRISTINE
Last Name:GROSS
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 LYNN ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-4231
Mailing Address - Country:US
Mailing Address - Phone:518-356-4422
Mailing Address - Fax:
Practice Address - Street 1:319 S MANNING BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1742
Practice Address - Country:US
Practice Address - Phone:518-435-0842
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303905363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ35729Medicare UPIN
NYRA5660Medicare ID - Type Unspecified