Provider Demographics
NPI:1205392610
Name:KNUDSON, MARK JAMES
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270246
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-7206
Mailing Address - Country:US
Mailing Address - Phone:414-416-4447
Mailing Address - Fax:
Practice Address - Street 1:3264 S 97TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4206
Practice Address - Country:US
Practice Address - Phone:414-899-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0198162OtherFENCE INSTALLATION