Healthcare Provider Details

I. General information

NPI: 1558275743
Provider Name (Legal Business Name): DYLAN KRUSE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 NW THOMPSON WAY
GRANTS PASS OR
97526-1200
US

IV. Provider business mailing address

1527 NW THOMPSON WAY
GRANTS PASS OR
97526-1200
US

V. Phone/Fax

Practice location:
  • Phone: 541-690-4577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number29275
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: