Provider Demographics
NPI:1710924493
Name:KNOTT, TARA M (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:KNOTT
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 1:1380 COWELL FARM ROAD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889
Mailing Address - Country:US
Mailing Address - Phone:252-946-2101
Mailing Address - Fax:252-946-9896
Practice Address - Street 1:1380 COWELL FARM ROAD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889
Practice Address - Country:US
Practice Address - Phone:252-946-2101
Practice Address - Fax:252-946-9896
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891175AMedicaid
NC1175AOtherBLUE CROSS
G11656Medicare UPIN
NC2262022Medicare ID - Type Unspecified