Provider Demographics
NPI:1811639198
Name:KRICHBAUM, ROBERT CLARK JR (CPNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLARK
Last Name:KRICHBAUM
Suffix:JR
Gender:M
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 MONTERO RD NE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-9165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2561 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3313
Practice Address - Country:US
Practice Address - Phone:248-682-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704388574363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics