Provider Demographics
NPI:1700622693
Name:KNUDSEN, DARRYL R (AB, MIA)
Entity type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:R
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:AB, MIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 60TH ST STE 10
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2369
Mailing Address - Country:US
Mailing Address - Phone:510-835-2505
Mailing Address - Fax:510-835-1062
Practice Address - Street 1:954 60TH ST STE 10
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2369
Practice Address - Country:US
Practice Address - Phone:510-508-6683
Practice Address - Fax:510-835-1062
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker