Provider Demographics
NPI:1023851565
Name:KRUK, BENJAMIN THOMAS (INDEPENDENT DUTY COR)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:KRUK
Suffix:
Gender:M
Credentials:INDEPENDENT DUTY COR
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:THOMAS
Other - Last Name:KRUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INDEPENDENT DUTY COR
Mailing Address - Street 1:3504 KELSEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3516
Mailing Address - Country:US
Mailing Address - Phone:702-960-2719
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:BUILDING 14
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:92124
Practice Address - Country:US
Practice Address - Phone:702-960-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic