Healthcare Provider Details

I. General information

NPI: 1356072953
Provider Name (Legal Business Name): MARK KNOBLAUCH NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3326 N 3RD AVE STE 201
PHOENIX AZ
85013-4336
US

IV. Provider business mailing address

3326 N 3RD AVE STE 201
PHOENIX AZ
85013-4336
US

V. Phone/Fax

Practice location:
  • Phone: 602-625-7944
  • Fax: 602-895-7576
Mailing address:
  • Phone: 602-625-7944
  • Fax: 602-865-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number276844
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: