Healthcare Provider Details

I. General information

NPI: 1336867258
Provider Name (Legal Business Name): ANGELA FAASALIA POLU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST STE 206
HONOLULU HI
96813-2411
US

IV. Provider business mailing address

1621 DOLE ST APT 403
HONOLULU HI
96822-4835
US

V. Phone/Fax

Practice location:
  • Phone: 808-528-3888
  • Fax:
Mailing address:
  • Phone: 808-398-9266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1340
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: