Provider Demographics
NPI:1841651809
Name:KNACKSTEDT MEDICAL GROUP INC.
Entity type:Organization
Organization Name:KNACKSTEDT MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNACKSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-730-5603
Mailing Address - Street 1:7218 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6624
Mailing Address - Country:US
Mailing Address - Phone:505-730-5603
Mailing Address - Fax:505-554-2313
Practice Address - Street 1:7218 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6624
Practice Address - Country:US
Practice Address - Phone:505-730-5603
Practice Address - Fax:505-554-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty