Provider Demographics
NPI:1992051478
Name:KNUDSON, CHARLES ROY (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROY
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 19-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5969
Mailing Address - Country:US
Mailing Address - Phone:312-664-3278
Mailing Address - Fax:312-695-5774
Practice Address - Street 1:675 N SAINT CLAIR ST STE 19-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5969
Practice Address - Country:US
Practice Address - Phone:312-664-3278
Practice Address - Fax:312-695-5774
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004374363A00000X
NC0010-07298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004374OtherILLINOIS PHYSICIAN ASSISTANT LICENSE NUMBER