Provider Demographics
NPI:1831101112
Name:GROTH, VERONICA A (NPP)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:A
Last Name:GROTH
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MARK TWAIN LN
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1764
Mailing Address - Country:US
Mailing Address - Phone:631-689-2410
Mailing Address - Fax:
Practice Address - Street 1:4655 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2579
Practice Address - Country:US
Practice Address - Phone:631-327-5395
Practice Address - Fax:631-642-7955
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400489363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY96N761Medicare ID - Type Unspecified