Provider Demographics
NPI:1760099105
Name:KRUTIKOV, ROMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:KRUTIKOV
Suffix:
Gender:M
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 1:301 HEIGHTS LN APT 8F
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-7618
Mailing Address - Country:US
Mailing Address - Phone:267-255-3752
Mailing Address - Fax:
Practice Address - Street 1:100 EAGLEVILLE RD
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-1829
Practice Address - Country:US
Practice Address - Phone:267-255-3752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant