Provider Demographics
NPI:1629244173
Name:KNUTSON, TAMRA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:MARIE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMRA
Other - Middle Name:MARIE
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 N COMMERCIAL ST #100
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956
Mailing Address - Country:US
Mailing Address - Phone:920-722-1840
Mailing Address - Fax:
Practice Address - Street 1:333 N COMMERCIAL ST #100
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-722-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55514-0202085R0202X
NC1347542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology