Healthcare Provider Details

I. General information

NPI: 1366296105
Provider Name (Legal Business Name): ANTONE TAVARES IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

459 PATTERSON RD # 3B2
HONOLULU HI
96819-1522
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-0320
  • Fax:
Mailing address:
  • Phone: 808-433-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number62340
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: