Provider Demographics
NPI:1558461921
Name:KRUEGER, SUSAN J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:KRUEGER
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 1:1001 LAKESIDE AVENUE
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12301 SNOW RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130-1002
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:216-265-4386
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2283809Medicaid
P47754Medicare UPIN
KRPA18431Medicare ID - Type Unspecified