Provider Demographics
NPI:1649698366
Name:GROSS, SIERRA DAWN (MD)
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:DAWN
Last Name:GROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:DAWN
Other - Last Name:GROSS STALLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1333 W 5TH ST, STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-675-2650
Mailing Address - Fax:307-675-2651
Practice Address - Street 1:1333 W 5TH ST, STE 112
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-675-2650
Practice Address - Fax:307-675-2651
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10930A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY147313100Medicaid