Provider Demographics
NPI:1760039051
Name:BAK, TIMOTHY M (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:BAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:551 LONE PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-9403
Mailing Address - Country:US
Mailing Address - Phone:541-296-7724
Mailing Address - Fax:541-296-7605
Practice Address - Street 1:551 LONE PINE BLVD
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9403
Practice Address - Country:US
Practice Address - Phone:541-296-7724
Practice Address - Fax:541-296-7605
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA195591OtherPA-C MEDICAL LICENSE