Provider Demographics
NPI:1194900084
Name:KNOTT, HEATHER LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LYNN
Last Name:KNOTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:REGWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:12901 SE 97TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7902
Mailing Address - Country:US
Mailing Address - Phone:503-912-4788
Mailing Address - Fax:503-912-4787
Practice Address - Street 1:12901 SE 97TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7902
Practice Address - Country:US
Practice Address - Phone:503-912-4788
Practice Address - Fax:503-912-4787
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1586612084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500723940Medicaid