Healthcare Provider Details

I. General information

NPI: 1245230937
Provider Name (Legal Business Name): STEPHEN JOHN KNOBLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 E GARFIELD AVE
GETTYSBURG SD
57442-1325
US

IV. Provider business mailing address

306 S BROADWAY ST
GETTYSBURG SD
57442-1506
US

V. Phone/Fax

Practice location:
  • Phone: 605-765-2273
  • Fax: 605-765-2273
Mailing address:
  • Phone: 605-765-2790
  • Fax: 605-765-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0290
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: