Provider Demographics
NPI:1023050952
Name:KNACKSTEDT, NATHANIEL C (DO)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:C
Last Name:KNACKSTEDT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:HOISINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67544-1706
Mailing Address - Country:US
Mailing Address - Phone:620-653-5067
Mailing Address - Fax:620-653-5070
Practice Address - Street 1:252 W 9TH ST STE A
Practice Address - Street 2:
Practice Address - City:HOISINGTON
Practice Address - State:KS
Practice Address - Zip Code:67544-1700
Practice Address - Country:US
Practice Address - Phone:620-653-2386
Practice Address - Fax:620-653-4186
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-30779207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS389905OtherBCBS
KS200267010BMedicaid
KS389905Medicare ID - Type Unspecified
KSI15468Medicare UPIN