MEDICARE: MARK JAMES KNUDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0198162	OTHER		FENCE INSTALLATION

General Provider Information

NPI Number	:	1205392610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JAMES KNUDSON

Provider Business Mailing Address
First Line	:	PO BOX 270246
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53227-7206
Country	:	US
Telephone Number	:	414-416-4447
Fax Number	:

Provider Business Practice Location Address
First Line	:	3264 S 97TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53227-4206
Country	:	US
Telephone Number	:	414-899-4554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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