Basic Information
| Provider Information | |||||||||
| NPI: | 1235395104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | CARLISE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FAMILY NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX MED | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852754517 | ||||||||
| FaxNumber: | 5854429201 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852754517 | ||||||||
| FaxNumber: | 5854429201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3341241 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02777122 | 05 | NY | MEDICAID | P00838557 | 01 | NY | MEDICARE RAILROAD | OTHER |