Provider Demographics
NPI:1902208671
Name:KRUSEMAN, PHILIP ANTHONY N (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:ANTHONY N
Last Name:KRUSEMAN
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 1:12861 NIGHTINGALE ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7028
Mailing Address - Country:US
Mailing Address - Phone:763-412-2803
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:763-412-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant