Provider Demographics
NPI:1740529403
Name:BAKKUM, MATTHEW PAUL (DPT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PAUL
Last Name:BAKKUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0196
Mailing Address - Country:US
Mailing Address - Phone:701-400-9793
Mailing Address - Fax:
Practice Address - Street 1:1000 TACOMA AVE STE 500
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-7093
Practice Address - Country:US
Practice Address - Phone:701-751-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist