Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 3203 | WV |
NPI | 1043530074 |
---|---|
Provider Name | Mr. Kimball Scott Knackstedt |
First Address | Reno, NV 89502-2055 |
Second Address | Reno, NV 89502-1198 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2010 |
Last Update Date | 26/12/2019 |