Healthcare Provider Details

I. General information

NPI: 1952829293
Provider Name (Legal Business Name): THERESA FAUST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3-3420 KUHIO HWY STE B
LIHUE HI
96766-1098
US

IV. Provider business mailing address

706 TRAVELER LN
MADISON WI
53718-3142
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-1357
  • Fax:
Mailing address:
  • Phone: 608-225-7238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD780
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: