Basic Information
| Provider Information | |||||||||
| NPI: | 1154677854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISALES | ||||||||
| FirstName: | DIEGO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 259 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337329 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03504529 | 05 | NY | MEDICAID |