Healthcare Provider Details

I. General information

NPI: 1700971223
Provider Name (Legal Business Name): JAMES LYLE KNOLL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 BACKCOUNTRY DR.
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

2295 BACKCOUNTRY DR.
PAGOSA SPRINGS CO
81147
US

V. Phone/Fax

Practice location:
  • Phone: 970-731-4262
  • Fax: 970-731-4262
Mailing address:
  • Phone: 970-731-4262
  • Fax: 970-731-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34693
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberC53409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: