Provider Demographics
NPI:1376852772
Name:KNACK, KEVIN MICHAEL JR (NP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:KNACK
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 REDWOOD HWY FRONTAGE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3055
Mailing Address - Country:US
Mailing Address - Phone:866-247-4292
Mailing Address - Fax:866-247-4292
Practice Address - Street 1:655 REDWOOD HWY FRONTAGE RD STE 240
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3055
Practice Address - Country:US
Practice Address - Phone:866-247-4292
Practice Address - Fax:866-247-4292
Is Sole Proprietor?:No
Enumeration Date:2010-10-02
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014679163W00000X, 363LP0808X
WARN60313579163W00000X
WAAP60313580363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025451Medicaid