Provider Demographics
NPI:1902923667
Name:KRUEGER, MATTHEW WILLIAM (ATC, EMTB)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:ATC, EMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 NE PACIFIC ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-232-0916
Mailing Address - Fax:
Practice Address - Street 1:4950 SE ROETHE RD.
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267
Practice Address - Country:US
Practice Address - Phone:503-353-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer