Provider Demographics
NPI:1902075294
Name:MCDONALD, KRUTI (PA)
Entity type:Individual
Prefix:
First Name:KRUTI
Middle Name:
Last Name:MCDONALD
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 1:901 GRAND AVE
Mailing Address - Street 2:APT 2B
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-1648
Mailing Address - Country:US
Mailing Address - Phone:201-776-8757
Mailing Address - Fax:
Practice Address - Street 1:901 GRAND AVE
Practice Address - Street 2:APT 2B
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-1648
Practice Address - Country:US
Practice Address - Phone:201-776-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP001090363AS0400X
NY012408-1363AS0400X
NJ25MP00109000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400041829Medicare PIN