Healthcare Provider Details

I. General information

NPI: 1225302995
Provider Name (Legal Business Name): RYAN WADA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

P.O. BOX 337
WAIMEA HI
96796-0337
US

V. Phone/Fax

Practice location:
  • Phone: 808-742-0999
  • Fax: 808-240-5576
Mailing address:
  • Phone: 808-240-2723
  • Fax: 808-240-5569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: