Provider Demographics
NPI:1386082758
Name:KROEGER, PHILLIP BRANDON
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRANDON
Last Name:KROEGER
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:PO BOX 1736
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-1736
Mailing Address - Country:US
Mailing Address - Phone:559-494-4676
Mailing Address - Fax:866-429-5719
Practice Address - Street 1:46278 PALOMA RD
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-8708
Practice Address - Country:US
Practice Address - Phone:559-494-4676
Practice Address - Fax:866-429-5719
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170832278P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary Diagnostics