Healthcare Provider Details

I. General information

NPI: 1225030406
Provider Name (Legal Business Name): RYAN SCOTT BAKKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N 4TH AVE E
NEWTON IA
50208-3135
US

IV. Provider business mailing address

204 N 4TH AVE E
NEWTON IA
50208-3135
US

V. Phone/Fax

Practice location:
  • Phone: 641-792-1273
  • Fax: 641-791-4852
Mailing address:
  • Phone: 641-792-1273
  • Fax: 641-791-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3471
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3471
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: