Provider Demographics
NPI:1043253677
Name:KNUCKLES, GWENDOLYN (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:KNUCKLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317A EXECUTIVE PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-830-1035
Mailing Address - Fax:
Practice Address - Street 1:2317A EXECUTIVE PARK CIRCLE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-830-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949904Medicaid
NC770605415OtherFEDERAL TAX ID
NC8949904Medicaid
NC2218351AMedicare ID - Type Unspecified