=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508952060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN R. KNUDSEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6046 PORTAL WAY STE 103
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98248-7829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-734-2330
-----------------------------------------------------
Fax | 360-733-3886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1260 MARALEE LANE
-----------------------------------------------------
City | BELLINGHAM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-393-4142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | MD00013215
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | MD00013215
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------