Healthcare Provider Details

I. General information

NPI: 1538580394
Provider Name (Legal Business Name): SHANNON OKETANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 KUKUI GROVE ST STE 3
LIHUE HI
96766-1639
US

IV. Provider business mailing address

4381 KUKUI GROVE ST STE 3
LIHUE HI
96766-1639
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-0144
  • Fax:
Mailing address:
  • Phone: 808-246-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3681
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: