Provider Demographics
NPI:1447925615
Name:KNAPP, WYATT ETHAN (NP)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:ETHAN
Last Name:KNAPP
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 SALK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-7346
Mailing Address - Country:US
Mailing Address - Phone:760-827-7200
Mailing Address - Fax:
Practice Address - Street 1:2176 SALK AVE STE 200
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7346
Practice Address - Country:US
Practice Address - Phone:760-827-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily