Healthcare Provider Details

I. General information

NPI: 1750809224
Provider Name (Legal Business Name): MARK JOSEPH KNOTTS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax: 440-922-0145
Mailing address:
  • Phone: 615-377-5603
  • Fax: 615-290-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2012035227
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: