Provider Demographics
NPI:1386803682
Name:KNUDSEN, LARA M (MD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 LIBERTY RD S STE 120
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5182
Mailing Address - Country:US
Mailing Address - Phone:971-599-1002
Mailing Address - Fax:
Practice Address - Street 1:4744 LIBERTY RD S STE 120
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5182
Practice Address - Country:US
Practice Address - Phone:971-599-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR155238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine