Provider Demographics
NPI:1215936034
Name:KNUTSON, HEATHER NICOLE (NP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:NICOLE
Other - Last Name:GASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1605 E RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6237
Mailing Address - Country:US
Mailing Address - Phone:208-939-6227
Mailing Address - Fax:208-939-6442
Practice Address - Street 1:1605 E RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6237
Practice Address - Country:US
Practice Address - Phone:208-939-6227
Practice Address - Fax:208-939-6442
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP672A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00748833OtherRAILROAD MEDICARE 08/01/09
IDNP 672AOtherNP LICENSE
IDP00748833OtherRAILROAD MEDICARE 08/01/09
ID13448151Medicare UPIN