Healthcare Provider Details

I. General information

NPI: 1780352914
Provider Name (Legal Business Name): CHAD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 YOUNG ST APT H
HONOLULU HI
96814-1810
US

IV. Provider business mailing address

1226 YOUNG ST APT H
HONOLULU HI
96814-1810
US

V. Phone/Fax

Practice location:
  • Phone: 808-269-2237
  • Fax: 808-400-5892
Mailing address:
  • Phone: 808-269-2237
  • Fax: 808-400-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: