Provider Demographics
NPI:1609854173
Name:KNAPP, EDSON L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDSON
Middle Name:L
Last Name:KNAPP
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 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-0326
Mailing Address - Fax:907-235-0253
Practice Address - Street 1:4300 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7005
Practice Address - Country:US
Practice Address - Phone:907-235-0326
Practice Address - Fax:907-235-0253
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012387492085R0202X
TN472652085R0202X
AK1035092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004714Medicaid
VA185560OtherANTHEM BCBS
P00274027OtherRAILROAD MEDICARE
VA010216958Medicaid
VA00W914V01Medicare PIN
WV3810004714Medicaid
H87003Medicare UPIN