Provider Demographics
NPI:1356868301
Name:BAK, JOONKWON
Entity Type:Individual
Prefix:
First Name:JOONKWON
Middle Name:
Last Name:BAK
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 1:1825 EASTCHESTER RD # 7NW
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2301
Mailing Address - Country:US
Mailing Address - Phone:718-904-3101
Mailing Address - Fax:718-904-2827
Practice Address - Street 1:1825 EASTCHESTER RD # 7NW
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-3101
Practice Address - Fax:718-904-2827
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021224363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical