Provider Demographics
NPI:1679610794
Name:KRUK, LINDSEY MARIE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:MARIE
Last Name:KRUK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:MARIE
Other - Last Name:FEDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PLUMTREE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-6095
Mailing Address - Country:US
Mailing Address - Phone:410-569-9444
Mailing Address - Fax:410-569-4368
Practice Address - Street 1:104 PLUMTREE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6095
Practice Address - Country:US
Practice Address - Phone:410-569-9444
Practice Address - Fax:410-569-4368
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052814363A00000X
MDC0004761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant