Provider Demographics
NPI:1114352747
Name:KNUTSON, RAQUEL (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5616
Mailing Address - Country:US
Mailing Address - Phone:619-585-4050
Mailing Address - Fax:619-585-4054
Practice Address - Street 1:525 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5616
Practice Address - Country:US
Practice Address - Phone:619-585-4050
Practice Address - Fax:619-585-4054
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51382363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant