Provider Demographics
NPI:1821104647
Name:GRUDOWSKI, CHRISTOPHER PAUL (MSN/FNP)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:PAUL
Last Name:GRUDOWSKI
Suffix:
Gender:M
Credentials:MSN/FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6459 STATE HIGHWAY 56 # A
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-6423
Mailing Address - Country:US
Mailing Address - Phone:315-265-5401
Mailing Address - Fax:
Practice Address - Street 1:3 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1333
Practice Address - Country:US
Practice Address - Phone:315-493-4180
Practice Address - Fax:315-493-4188
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD3676Medicare ID - Type Unspecified
NYP75042Medicare UPIN