Provider Demographics
NPI:1649586041
Name:KRUSE, MAHGEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:MAHGEN
Middle Name:L
Last Name:KRUSE
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 1:1218 TROTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-6406
Mailing Address - Country:US
Mailing Address - Phone:931-490-7440
Mailing Address - Fax:931-490-7439
Practice Address - Street 1:1218 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6406
Practice Address - Country:US
Practice Address - Phone:931-490-7440
Practice Address - Fax:931-490-7439
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2833-23363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical