MEDICARE: MERRY CATHERINE GROSS CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	2478247	MN
2	367500000X	Certified Registered Nurse Anesthetist	143897	MN

General Provider Information

NPI Number	:	1790305845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERRY CATHERINE GROSS CRNA

Provider Business Mailing Address
First Line	:	2245 REILING RD
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55110-1023
Country	:	US
Telephone Number	:	815-871-4568
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 REILING RD
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55110-1023
Country	:	US
Telephone Number	:	815-871-4568
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2020
Last Update Date	:	08/29/2022

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