=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386803682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARA M KNUDSEN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 370 LINCOLN ST SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-4350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-599-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2755 COMMERCIAL ST SE # 101-327
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-4981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-599-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 155238
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------