Healthcare Provider Details

I. General information

NPI: 1912021940
Provider Name (Legal Business Name): DISA GAY B CAMACAYLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65-1230 MAMALAHOA HWY SUITE E11
KAMUELA HI
96743-8318
US

IV. Provider business mailing address

65-1230 MAMALAHOA HWY SUITE E11
KAMUELA HI
96743-8318
US

V. Phone/Fax

Practice location:
  • Phone: 808-885-7131
  • Fax:
Mailing address:
  • Phone: 808-885-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number05008661A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: