Provider Demographics
NPI:1962175109
Name:KRUKOW, PHILIP
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:KRUKOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2462 N 720 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-9712
Mailing Address - Country:US
Mailing Address - Phone:801-668-2901
Mailing Address - Fax:
Practice Address - Street 1:134 W 1180 N STE 5
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1483
Practice Address - Country:US
Practice Address - Phone:435-248-0333
Practice Address - Fax:435-248-0334
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12591198-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant