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:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:
Practice Address - Street 1:1600 DELTA WATERS RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA195591OtherPA-C MEDICAL LICENSE