Provider Demographics
NPI:1023103348
Name:KNOWLTON, CAROL J (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:KNOWLTON
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:P.O. BOX 254
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597
Mailing Address - Country:US
Mailing Address - Phone:253-847-5650
Mailing Address - Fax:253-847-5653
Practice Address - Street 1:3000 LIMITED LANE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-357-9392
Practice Address - Fax:360-357-9392
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0156219OtherLABOR & INDUSTRY
WA128044OtherLABOR & INDUSTRY
WA1108588Medicaid
WA8240541Medicaid
WAAB10957Medicare ID - Type UnspecifiedMEDICARE
WAA08755Medicare UPIN