Provider Demographics
NPI:1124041660
Name:KRUEGER, MICHAEL STEPHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHAN
Last Name:KRUEGER
Suffix:
Gender:M
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-254-1240
Mailing Address - Fax:360-397-3128
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1723
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01022363AM0700X
WAPA10004647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8486540Medicaid
WA8866357Medicare PIN