Healthcare Provider Details

I. General information

NPI: 1124041660
Provider Name (Legal Business Name): MICHAEL STEPHAN KRUEGER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SE 172ND AVE
VANCOUVER WA
98684
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax: 360-604-1723
Mailing address:
  • Phone: 360-254-1240
  • Fax: 360-397-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01022
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: