Provider Demographics
NPI:1518448158
Name:TRUKOVA, KRISTEN (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:TRUKOVA
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 ELISHA AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2676
Mailing Address - Country:US
Mailing Address - Phone:847-872-6164
Mailing Address - Fax:
Practice Address - Street 1:2520 ELISHA AVE OFC
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2676
Practice Address - Country:US
Practice Address - Phone:847-872-6164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003487133V00000X
IL085007260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered