Healthcare Provider Details

I. General information

NPI: 1790162980
Provider Name (Legal Business Name): PANIOLO PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/27/2015
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD16732
License Number StateHI

VIII. Authorized Official

Name: DR. BRETT COLIN FERGUSON
Title or Position: SOLE MEMBER
Credential: MD
Phone: 808-887-6543