Provider Demographics
NPI:1033655477
Name:KRUKEMYER, DAVID PAUL (ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
Last Name:KRUKEMYER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W55N223 WOODMERE CT APT 1
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2831
Mailing Address - Country:US
Mailing Address - Phone:419-308-6915
Mailing Address - Fax:
Practice Address - Street 1:12800 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2418
Practice Address - Country:US
Practice Address - Phone:262-243-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAT-3442255A2300X
WI2527-392255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty