Healthcare Provider Details

I. General information

NPI: 1417276304
Provider Name (Legal Business Name): RYAN J. BAKKO MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S MAPLE ST SUITE 200
WACONIA MN
55387-1733
US

IV. Provider business mailing address

4200 DAHLBERG DR SUITE 300
GOLDEN VALLEY MN
55422-4840
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2163
  • Fax: 952-442-5903
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10732
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: