Provider Demographics
NPI:1083605307
Name:KNACKSTEDT, VIRGIL ERNEST (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:ERNEST
Last Name:KNACKSTEDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5064
Mailing Address - Country:US
Mailing Address - Phone:360-493-4601
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:3417 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5064
Practice Address - Country:US
Practice Address - Phone:360-493-4601
Practice Address - Fax:360-493-4603
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019853174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8288805Medicaid
WA8288805Medicaid
WAA08941Medicare UPIN