Healthcare Provider Details

I. General information

NPI: 1922410430
Provider Name (Legal Business Name): JONATHAN KNOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 RAWLINS ST
CHEYENNE WY
82001-1800
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-2562
  • Fax: 307-638-2074
Mailing address:
  • Phone: 307-773-8237
  • Fax: 307-773-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number12750A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT206863
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number12750A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: