| Organization Name: | KNACKSTEDT MEDICAL GROUP INC. |
| NPI Number: | 1841651809 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SHIRLEY KNACKSTEDT (CO-OWNER) |
| Mailing Address: | 7218 4th St Nw Los Ranchos |
| State: | NM US |
| Postal Code: | 871076624 |
| Phone Number: | 5057305603 |
| Fax Number: | 5055542313 |
| NPI Enumeration Date: | 03/17/2016 |
| NPI Last Update Date: | 03/17/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |