Healthcare Provider Details

I. General information

NPI: 1265405864
Provider Name (Legal Business Name): JASON KNUDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N 10TH ST
SPEARFISH SD
57783
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MEDICAL STAFF SERVICES
RAPID CITY SD
57701-6000
US

V. Phone/Fax

Practice location:
  • Phone: 605-642-8414
  • Fax: 605-642-8618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5441
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: