Healthcare Provider Details

I. General information

NPI: 1821977471
Provider Name (Legal Business Name): PATRICK KRUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 S 75TH ST
OMAHA NE
68124-1700
US

IV. Provider business mailing address

1799 BLACKTHORN ST
COUNCIL BLUFFS IA
51503-5406
US

V. Phone/Fax

Practice location:
  • Phone: 402-361-5700
  • Fax:
Mailing address:
  • Phone: 720-417-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95424523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: