Provider Demographics
NPI:1356072953
Name:KNOBLAUCH, MARK (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KNOBLAUCH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 N 3RD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4336
Mailing Address - Country:US
Mailing Address - Phone:602-625-7944
Mailing Address - Fax:602-865-7576
Practice Address - Street 1:3326 N 3RD AVE STE 201
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4336
Practice Address - Country:US
Practice Address - Phone:602-625-7944
Practice Address - Fax:602-895-7576
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ276844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily