Healthcare Provider Details

I. General information

NPI: 1427808211
Provider Name (Legal Business Name): MIGUEL CLYDE MCQUEEN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WAIANUENUE AVE
HILO HI
96720-2094
US

IV. Provider business mailing address

201 FAIRCREST DR UNIT 1295
CLEBURNE TX
76033-9753
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License Number81654
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: