Healthcare Provider Details

I. General information

NPI: 1659201507
Provider Name (Legal Business Name): CRYSTAL KERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-1841 FORT WEAVER RD
EWA BEACH HI
96706-1909
US

IV. Provider business mailing address

91-501 EWA BEACH RD APT A
EWA BEACH HI
96706-2972
US

V. Phone/Fax

Practice location:
  • Phone: 808-681-3500
  • Fax:
Mailing address:
  • Phone: 808-778-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: