Healthcare Provider Details

I. General information

NPI: 1740602341
Provider Name (Legal Business Name): MATTHEW GREGORY KNOWLSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD SUITE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-2929
  • Fax: 330-729-1841
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN372394
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN604731
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: