Healthcare Provider Details

I. General information

NPI: 1588854871
Provider Name (Legal Business Name): JEFFREY D KROUSKOP RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 TONGASS DR
SITKA AK
99835-9416
US

IV. Provider business mailing address

222 TONGASS DRIVE
SITKA AK
99835
US

V. Phone/Fax

Practice location:
  • Phone: 907-966-8386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number262262-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: