Healthcare Provider Details

I. General information

NPI: 1003883067
Provider Name (Legal Business Name): MARCIE KROSKA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 2ND ST E
BRADENTON FL
34208-1042
US

IV. Provider business mailing address

367 S. GULPH RD ATTN: IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-746-5111
  • Fax: 941-745-7233
Mailing address:
  • Phone: 941-746-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108805
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: