Healthcare Provider Details

I. General information

NPI: 1356167845
Provider Name (Legal Business Name): CHASE KRUEGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2024
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 N MAIN
CEDAR SPRINGS MI
49319-8041
US

IV. Provider business mailing address

2914 GREEN MEADOW DR APT 5
JENISON MI
49428-9578
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-4650
  • Fax:
Mailing address:
  • Phone: 616-920-4650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: