Healthcare Provider Details

I. General information

NPI: 1346690625
Provider Name (Legal Business Name): DANE BAY M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 GRIFFIN AVE
ENUMCLAW WA
98022-2369
US

IV. Provider business mailing address

3021 GRIFFIN AVE
ENUMCLAW WA
98022-2369
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-6511
  • Fax: 253-272-0419
Mailing address:
  • Phone: 360-825-6511
  • Fax: 253-272-0419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125069413
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60947429
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier2141678
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: