Healthcare Provider Details

I. General information

NPI: 1093223760
Provider Name (Legal Business Name): PAUL JOHN GRUBNER JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 CHAMPLIN AVE
UTICA NY
13502-4830
US

IV. Provider business mailing address

2209 GENESEE STREET BUSINESS OFFICE ROOM 310
UTICA NY
13501-5930
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-6000
  • Fax:
Mailing address:
  • Phone: 315-801-3282
  • Fax: 315-801-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: