Healthcare Provider Details

I. General information

NPI: 1972553220
Provider Name (Legal Business Name): WALLACE H KNAPP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD07935
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: