Philip Krukow

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

12591198-1206 Issued in UT

Practice address

30 S Tooele Blvd
Tooele, UT 84074-2093

Phone

(435) 248-0333

Fax

(435) 248-0334

NPI assigned

Jul 25, 2021

Last updated

Jan 29, 2026By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Patrick Green MD PLLCGroup PAC ID 6204000102, 8 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: philip.krukow.1@3781.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Patrick Green MD PLLC

  dba Bonneville Family Practice

  • Primary Care Clinic/Center
  • Tooele, UT
  • NPI 1518256650
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1627171200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1769644800000",
    "number": "1962175109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2462 N 720 W",
            "city": "CLINTON",
            "state": "UT",
            "postal_code": "840159712",
            "telephone_number": "801-668-2901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30 S TOOELE BLVD",
            "city": "TOOELE",
            "state": "UT",
            "postal_code": "840742093",
            "telephone_number": "435-248-0333",
            "fax_number": "435-248-0334"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KRUKOW",
        "first_name": "PHILIP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-07-25",
        "last_updated": "2026-01-29",
        "certification_date": "2026-01-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "12591198-1206",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jesse Knight, MD
• Natalie Knudsen
• Kellie Lee Korth
• Cherise Kortie
• Mackenzi Kough
• Randy Kwon, DMD
• Subrina Langston
• Lanny F Duclos OD PC (Eye Health Professionals)
• Michele Marie Larson, FNP
• Spencer Larson, DO

• Physician Assistant in Tooele, UT
• Providers in Tooele, UT by specialty
• Physician Assistant in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.