Healthcare Provider Details

I. General information

NPI: 1740586957
Provider Name (Legal Business Name): KAPAA PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4-1461 KUHIO HWY
KAPAA HI
96746-1715
US

IV. Provider business mailing address

4-1461 KUHIO HWY
KAPAA HI
96746-1715
US

V. Phone/Fax

Practice location:
  • Phone: 808-220-7062
  • Fax: 808-822-0938
Mailing address:
  • Phone: 808-220-7062
  • Fax: 808-822-0938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15126
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15518
License Number StateHI

VIII. Authorized Official

Name: DR. JESSE TZU TAN LAM
Title or Position: MANAGER
Credential: M.D.
Phone: 808-220-7062