Healthcare Provider Details

I. General information

NPI: 1184440992
Provider Name (Legal Business Name): THEA ANN CAYABAN DE VERO PT/PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

POHAKEA ELEMENTARY SCHOOL 91750 FORT WEAVER ROAD
EWA BEACH HI
96706
US

IV. Provider business mailing address

94-333 MOKUOLA ST APT 308
WAIPAHU HI
96797-6320
US

V. Phone/Fax

Practice location:
  • Phone: 808-689-1290
  • Fax:
Mailing address:
  • Phone: 808-636-3018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberPTA-582
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: