Provider Demographics
NPI:1194731000
Name:KNOWLTON, R. MARTIN (RPA)
Entity type:Individual
Prefix:
First Name:R.
Middle Name:MARTIN
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 EVERETT ROAD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-453-9088
Mailing Address - Fax:518-689-3895
Practice Address - Street 1:121 EVERETT ROAD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-453-9088
Practice Address - Fax:518-689-3895
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000488363AS0400X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01276535Medicaid
NY01276535Medicaid
NYDD1640Medicare ID - Type Unspecified