=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225534977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP DOUGLAS KNESE CNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2018
-----------------------------------------------------
Last Update Date | 07/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 W DIVISION ST
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56301-3926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-389-2727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4498 UGSTAD RD UNIT 217
-----------------------------------------------------
City | HERMANTOWN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55811-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-491-0853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 247144-30
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5765
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------