Provider Demographics
NPI:1295109478
Name:KRUSE, EMILY JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
Last Name:KRUSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JEAN
Other - Last Name:BOARDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:705 N SIOUX POINT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5091
Mailing Address - Country:US
Mailing Address - Phone:605-217-5500
Mailing Address - Fax:605-217-5515
Practice Address - Street 1:705 N SIOUX POINT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5091
Practice Address - Country:US
Practice Address - Phone:605-217-5500
Practice Address - Fax:605-217-5515
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1010363A00000X
IA079778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant