Provider Demographics
NPI:1508952060
Name:KNUDSEN, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MARALEE LANE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226
Mailing Address - Country:US
Mailing Address - Phone:360-393-4142
Mailing Address - Fax:
Practice Address - Street 1:6046 PORTAL WAY
Practice Address - Street 2:STE 103
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-7829
Practice Address - Country:US
Practice Address - Phone:360-734-2330
Practice Address - Fax:360-733-3886
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013215207PE0004X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1466705Medicaid
WA50D0856491OtherCLIA
WA5824KNOtherREG RYDER
WA151150OtherL&I
WA151150OtherL&I
WA1466705Medicaid
WA50D0856491OtherCLIA