Provider Demographics
NPI:1043640840
Name:GROSS, ERNEST JAY (CRNA)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:JAY
Last Name:GROSS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-1514
Mailing Address - Country:US
Mailing Address - Phone:205-919-0863
Mailing Address - Fax:
Practice Address - Street 1:206 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1514
Practice Address - Country:US
Practice Address - Phone:205-919-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329494367500000X
FLARNP11000776367500000X
NC52674367500000X
SC27565367500000X
IAD166143367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered