Healthcare Provider Details

I. General information

NPI: 1285688408
Provider Name (Legal Business Name): MARK K IWASAKI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 KEOLU DR SUITE 104
KAILUA HI
96734-3871
US

IV. Provider business mailing address

PO BOX 1440
KAILUA HI
96734-1440
US

V. Phone/Fax

Practice location:
  • Phone: 808-262-2292
  • Fax:
Mailing address:
  • Phone: 808-262-2292
  • Fax: 808-262-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2471
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: