Provider Demographics
NPI:1477542447
Name:NIKOMBORIRAK, JAKDEJ (MD)
Entity type:Individual
Prefix:
First Name:JAKDEJ
Middle Name:
Last Name:NIKOMBORIRAK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1617
Mailing Address - Fax:
Practice Address - Street 1:1013 E EDISON AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1115
Practice Address - Country:US
Practice Address - Phone:509-837-1587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036445207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG69338Medicare UPIN