Provider Demographics
NPI:1083486344
Name:BAE, JOHN YONG
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:YONG
Last Name:BAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-5459
Mailing Address - Country:US
Mailing Address - Phone:224-210-0122
Mailing Address - Fax:
Practice Address - Street 1:1717 W CRYSTAL LN
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-5459
Practice Address - Country:US
Practice Address - Phone:224-210-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028606363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health