Healthcare Provider Details

I. General information

NPI: 1528376597
Provider Name (Legal Business Name): CRYSTAL CHANEL CABANSAG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 LILIHA ST STE 302
HONOLULU HI
96817-1605
US

IV. Provider business mailing address

11240 SAN MATEO DR APT A
LOMA LINDA CA
92354-3463
US

V. Phone/Fax

Practice location:
  • Phone: 808-521-4344
  • Fax:
Mailing address:
  • Phone: 817-308-5339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: