Provider Demographics
NPI:1063738722
Name:SKRUCK, BERNADETTE T (PA)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:T
Last Name:SKRUCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 PERSIMMON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3354
Mailing Address - Country:US
Mailing Address - Phone:312-927-6634
Mailing Address - Fax:
Practice Address - Street 1:1348 WALTON WAY STE 5700
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5110
Practice Address - Country:US
Practice Address - Phone:706-722-8242
Practice Address - Fax:706-722-8351
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6394363AS0400X
DEC5-0001352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical