Provider Demographics
NPI:1912359415
Name:KNOTTS, MICHAEL (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KNOTTS
Suffix:
Gender:M
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:7001 HIGHWAY 614
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39562-6483
Practice Address - Country:US
Practice Address - Phone:228-588-6622
Practice Address - Fax:228-588-9399
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05239768Medicaid