MEDICARE: GWENDOLYN K KNOTTS

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	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	RN250278	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972551497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN K KNOTTS

Provider Business Mailing Address
First Line	:	742 W HIGHLAND AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92405-3839
Country	:	US
Telephone Number	:	909-881-7320
Fax Number	:	909-881-7330

Provider Business Practice Location Address
First Line	:	7675 STERLING AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-4738
Country	:	US
Telephone Number	:	909-381-8983
Fax Number	:	909-381-2933

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2007

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