Provider Demographics
NPI:1518124114
Name:KNUDSON-JOHNSON, MELISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:M
Last Name:KNUDSON-JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 3RD ST STE 203
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3251
Mailing Address - Country:US
Mailing Address - Phone:307-333-6940
Mailing Address - Fax:888-964-2162
Practice Address - Street 1:940 E 3RD ST STE 203
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3251
Practice Address - Country:US
Practice Address - Phone:307-333-6940
Practice Address - Fax:888-964-2162
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10050A208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics