Healthcare Provider Details

I. General information

NPI: 1144835018
Provider Name (Legal Business Name): CHAYATA WONGPOJANEE OTSUKA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WAIANUENUE AVE
HILO HI
96720-2089
US

IV. Provider business mailing address

585 PILINUI PL
HILO HI
96720-6232
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-3000
  • Fax:
Mailing address:
  • Phone: 808-854-1343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-3033
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: