Healthcare Provider Details

I. General information

NPI: 1780663781
Provider Name (Legal Business Name): BRENDA J KRUSE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E MADISON AVE SUITE 400A
MANKATO MN
56001-5473
US

IV. Provider business mailing address

1230 E MAIN ST PO BOX 8674
MANKATO MN
56001-5066
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-1811
  • Fax:
Mailing address:
  • Phone: 507-625-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9539
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: