Provider Demographics
NPI:1992022693
Name:KRUENEGEL, KEVIN LOUIS (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LOUIS
Last Name:KRUENEGEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-8176
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:555 BLACK OAK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8447
Practice Address - Country:US
Practice Address - Phone:541-789-8176
Practice Address - Fax:541-789-4806
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005820363A00000X
OR196530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129392AMedicaid
GA003129392AMedicaid