Basic Information
Provider Information | |||||||||
NPI: | 1306893359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRASKA | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2505 | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973082505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888283197 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2963 E COPPER POINT DR | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836429055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089470590 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 09/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2004-0116 | NM | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD175591 | OR | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 10013393 | 01 |   | LOVELACE | OTHER | 62157256 | 05 | NM |   | MEDICAID | 85-0236178-031 | 01 |   | MOLINA HEALTHCARE SALUD | OTHER | 85-0236178-021 | 01 |   | MOLINA HEALTHCARE | OTHER | 14924 | 01 |   | PRESBY- TERIAN | OTHER |