Provider Demographics
NPI:1619052289
Name:BAKKEN, KENNETH LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LYNN
Last Name:BAKKEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N 30TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-3364
Mailing Address - Country:US
Mailing Address - Phone:253-779-5858
Mailing Address - Fax:253-779-5757
Practice Address - Street 1:2200 N 30TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-3364
Practice Address - Country:US
Practice Address - Phone:253-779-5858
Practice Address - Fax:253-779-5757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP000007532083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1116359Medicaid
WAOP00000753OtherLICENSE
WAOP00000753OtherLICENSE
WAGAB29512Medicare ID - Type Unspecified
WAOP00000753OtherLICENSE