Provider Demographics
NPI:1326096124
Name:KNUTESON, LAUREEN S (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:S
Last Name:KNUTESON
Suffix:
Gender:F
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 1:707 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2209
Mailing Address - Country:US
Mailing Address - Phone:812-334-5081
Mailing Address - Fax:812-334-5091
Practice Address - Street 1:707 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2209
Practice Address - Country:US
Practice Address - Phone:812-334-5081
Practice Address - Fax:812-334-5091
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1105-023363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42980300Medicaid
WI6933OtherDEAN HEALTH INSURANCE
WI056874150Medicare PIN
WI970008896Medicare PIN
WI42980300Medicaid