Provider Demographics
NPI:1285251835
Name:BAKKEN, KYLE (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:BAKKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2059
Mailing Address - Country:US
Mailing Address - Phone:086-374-2026
Mailing Address - Fax:
Practice Address - Street 1:507 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2059
Practice Address - Country:US
Practice Address - Phone:086-374-2026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN71914207Q00000X
WI84588-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine