Healthcare Provider Details

I. General information

NPI: 1356547947
Provider Name (Legal Business Name): CHRISTOPHER DALE KNOTTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3830 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8889
  • Fax:
Mailing address:
  • Phone: 505-842-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101253973
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2012-00384
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25651
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD2015-0050
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: