Provider Demographics
NPI:1659984631
Name:BAVOR, KORDALE TRE (NP)
Entity Type:Individual
Prefix:MR
First Name:KORDALE
Middle Name:TRE
Last Name:BAVOR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 204TH AVE E STE 1300
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6537
Mailing Address - Country:US
Mailing Address - Phone:253-848-8797
Mailing Address - Fax:
Practice Address - Street 1:10004 204TH AVE E STE 1300
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6537
Practice Address - Country:US
Practice Address - Phone:253-848-8797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61422757363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics