Provider Demographics
NPI:1689983884
Name:KROTO, BRYN LAUREN (PA-C)
Entity type:Individual
Prefix:MS
First Name:BRYN
Middle Name:LAUREN
Last Name:KROTO
Suffix:
Gender:F
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 1:1625 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-4330
Mailing Address - Country:US
Mailing Address - Phone:520-694-0111
Mailing Address - Fax:
Practice Address - Street 1:1625 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4330
Practice Address - Country:US
Practice Address - Phone:520-694-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60907835Medicaid
CO276875SL2GMedicare PIN
CO280568YMGXMedicare PIN