Healthcare Provider Details

I. General information

NPI: 1053812990
Provider Name (Legal Business Name): PANIOLO PEDIATRIC AND FAMILY MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64-1032 MAMALAHOA HWY STE 204
KAMUELA HI
96743-8441
US

IV. Provider business mailing address

PO BOX 6149
KAMUELA HI
96743-6149
US

V. Phone/Fax

Practice location:
  • Phone: 808-887-6543
  • Fax: 808-887-6294
Mailing address:
  • Phone: 808-887-6543
  • Fax: 808-887-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD18820
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD16732
License Number StateHI

VIII. Authorized Official

Name: BRETT C. FERGUSON
Title or Position: PRESIDENT
Credential: MD
Phone: 808-887-6543