=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356010573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYLES KNUTSON, DPM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2021
-----------------------------------------------------
Last Update Date | 12/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 B AVE STE B
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97034-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-804-7579
-----------------------------------------------------
Fax | 503-210-0364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 B AVE STE S
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97034-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 35-804-7579
-----------------------------------------------------
Fax | 503-210-0364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MYLES KNUTSON
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 503-635-7742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------