Healthcare Provider Details

I. General information

NPI: 1376755330
Provider Name (Legal Business Name): HOLLY MARIE POAG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 ALA KALANIKAUMAKA ST. STE.B201
KOLOA HI
96756
US

IV. Provider business mailing address

PO BOX 669 ATTEN: RHONELLE C ACERET
WAIMEA HI
96796-0669
US

V. Phone/Fax

Practice location:
  • Phone: 808-742-0999
  • Fax: 808-742-0990
Mailing address:
  • Phone: 808-240-2723
  • Fax: 808-338-9420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101016537
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDOS-1820
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: