Healthcare Provider Details

I. General information

NPI: 1770790768
Provider Name (Legal Business Name): ALOIAMOA ANESI MBCHB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 06/10/2008

III. Provider practice location address

96796 TURNER DRIVE
PAGO PAGO AS
96799
US

IV. Provider business mailing address

PO BOX LBJTMC
PAGO PAGO AS
96799
US

V. Phone/Fax

Practice location:
  • Phone: 684-633-1683
  • Fax: 684-633-5107
Mailing address:
  • Phone: 684-633-1683
  • Fax: 684-633-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE12345
License Number StateAS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009C
License Number StateAS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: