Basic Information
| Provider Information | |||||||||
| NPI: | 1457885527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNUDSON | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST RM 3154 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3525 E LOUISE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083817312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2017 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | O-1570 | ID | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.