Provider Demographics
NPI:1003883067
Name:KROSKA, MARCIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:KROSKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:941-746-5111
Mailing Address - Fax:
Practice Address - Street 1:206 2ND ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1042
Practice Address - Country:US
Practice Address - Phone:941-746-5111
Practice Address - Fax:941-745-7233
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108805363A00000X
MI5601001892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP37070Medicare UPIN