Healthcare Provider Details

I. General information

NPI: 1891741864
Provider Name (Legal Business Name): KNOTT STREET DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE KNOTT ST
PORTLAND OR
97212-3014
US

IV. Provider business mailing address

301 NE KNOTT ST
PORTLAND OR
97212-3014
US

V. Phone/Fax

Practice location:
  • Phone: 503-253-2675
  • Fax: 503-253-4297
Mailing address:
  • Phone: 503-253-2675
  • Fax: 503-253-4297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD26393
License Number StateOR

VIII. Authorized Official

Name: DR. ERIC LEIF HANSON
Title or Position: PRESIDENT
Credential: MD
Phone: 503-253-3910