Provider Demographics
NPI:1578895652
Name:KRUG, COLLEEN MARY (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:KRUG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1228
Mailing Address - Country:US
Mailing Address - Phone:315-592-0721
Mailing Address - Fax:315-598-4733
Practice Address - Street 1:10 GEORGE ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3276
Practice Address - Country:US
Practice Address - Phone:315-598-4790
Practice Address - Fax:315-593-6195
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1091403OtherNCCPA CERTIFICATION
NH0764OtherSTAT OF NH LICENSE