Healthcare Provider Details

I. General information

NPI: 1841651809
Provider Name (Legal Business Name): KNACKSTEDT MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7218 4TH ST NW
LOS RANCHOS NM
87107-6624
US

IV. Provider business mailing address

7218 4TH ST NW
LOS RANCHOS NM
87107-6624
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-5603
  • Fax: 505-554-2313
Mailing address:
  • Phone: 505-730-5603
  • Fax: 505-554-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY KNACKSTEDT
Title or Position: CO-OWNER
Credential: CNP
Phone: 505-730-5603