Basic Information
| Provider Information | |||||||||
| NPI: | 1649212119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNUTSON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836421026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N LIBERTY ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M8704 | ID | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 806443100 | 05 | ID | MEDICAID |