Healthcare Provider Details

I. General information

NPI: 1174573497
Provider Name (Legal Business Name): GLENN J KRUSER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N WATER ST
EVANSVILLE WI
53536-1152
US

IV. Provider business mailing address

10 N WATER ST
EVANSVILLE WI
53536-1152
US

V. Phone/Fax

Practice location:
  • Phone: 608-882-5170
  • Fax: 608-882-6532
Mailing address:
  • Phone: 608-882-5170
  • Fax: 680-882-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number183-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: