Healthcare Provider Details

I. General information

NPI: 1366856569
Provider Name (Legal Business Name): BOWHEE SOHN GWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10414 BEARDSLEE BLVD STE 100
BOTHELL WA
98011-3205
US

IV. Provider business mailing address

955 POWELL AVE SW
RENTON WA
98057-2908
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-0658
  • Fax: 425-487-6761
Mailing address:
  • Phone: 425-277-1311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301105225
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60773048
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2086646
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: