Healthcare Provider Details

I. General information

NPI: 1023458700
Provider Name (Legal Business Name): JESSICA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S KING ST
HONOLULU HI
96813-3097
US

IV. Provider business mailing address

888 S KING ST
HONOLULU HI
96813-3097
US

V. Phone/Fax

Practice location:
  • Phone: 808-522-4469
  • Fax:
Mailing address:
  • Phone: 808-522-4469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD-21050
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: