Provider Demographics
NPI:1942762851
Name:KORTBAOUI, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KORTBAOUI
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 1:20 W 10TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-221-5520
Mailing Address - Fax:
Practice Address - Street 1:320 W 10TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6302
Practice Address - Country:US
Practice Address - Phone:509-221-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program