Provider Demographics
NPI:1124537550
Name:KNUDSEN, DANIEL THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19340 UPPER SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7954
Mailing Address - Country:US
Mailing Address - Phone:646-207-4642
Mailing Address - Fax:
Practice Address - Street 1:786 D ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE ELMENDORF RICHARDSON
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-384-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1145170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant