Provider Demographics
NPI:1235146515
Name:GROTH, DIANE M (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:GROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:315-464-5450
Mailing Address - Fax:315-464-6322
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-5450
Practice Address - Fax:315-464-6322
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02117733Medicaid
NY02117733Medicaid
NYJ400011722Medicare PIN