Provider Demographics
NPI:1013909043
Name:GRUSS, MARY S (ANP-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:GRUSS
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:IPPOLITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C
Mailing Address - Street 1:400 PATROON CREEK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-5014
Mailing Address - Country:US
Mailing Address - Phone:518-445-4444
Mailing Address - Fax:518-168-1665
Practice Address - Street 1:400 PATROON CREEK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5014
Practice Address - Country:US
Practice Address - Phone:518-445-4444
Practice Address - Fax:518-168-1665
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302625363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02643016Medicaid
NY02643016Medicaid
NYJ400002729Medicare PIN