Basic Information
| Provider Information | |||||||||
| NPI: | 1861412884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAK | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | KIRYANG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3949 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976034746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418821670 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 CHILOQUIN BLVD | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5417833273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A91888 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD164294 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500674133 | 05 | OR | MEDICAID |