Basic Information
| Provider Information | |||||||||
| NPI: | 1366856569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GWAK | ||||||||
| FirstName: | BOWHEE | ||||||||
| MiddleName: | SOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12800 BOTHELL EVERETT HWY STE 160 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982086644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253165180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2014 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301105225 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 60773048 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2086646 | 05 | WA | MEDICAID |