Healthcare Provider Details

I. General information

NPI: 1013514017
Provider Name (Legal Business Name): NICHOLAS KNUTSON MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2020
Last Update Date: 10/03/2020
Certification Date: 10/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 E BROADWAY BLVD STE 113
TUCSON AZ
85719-5908
US

IV. Provider business mailing address

4512 W HOLLY BERRY WAY
TUCSON AZ
85741-4087
US

V. Phone/Fax

Practice location:
  • Phone: 520-343-1238
  • Fax:
Mailing address:
  • Phone: 520-343-1238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: