Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | MD00044997 | WA |
NPI | 1063413938 |
---|---|
Provider Name | Dr. John B Bak |
First Address | Lakewood, WA 98499-3024 |
Second Address | Lakewood, WA 98499-3024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2005 |
Last Update Date | 24/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0216025 | STATE L&I (01) | WA |
0261681 | STATE L&I (01) | WA |
0261684 | STATE L&I (01) | WA |
0299315 | STATE L&I (01) | WA |
7077449 | (05) | WA |