Healthcare Provider Details

I. General information

NPI: 1083124135
Provider Name (Legal Business Name): KAIDDEN KELLY DMSC, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-184 HUALALAI RD STE 302
KAILUA KONA HI
96740-1719
US

IV. Provider business mailing address

75-184 HUALALAI RD STE 302
KAILUA KONA HI
96740-1719
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-0111
  • Fax: 808-365-5811
Mailing address:
  • Phone: 808-329-0111
  • Fax: 808-365-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-785
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: