Healthcare Provider Details

I. General information

NPI: 1386753903
Provider Name (Legal Business Name): WAHIAWA FAMILY PRACTICE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CALIFORNIA AVE SUITE 103
WAHIAWA HI
96786-1841
US

IV. Provider business mailing address

302 CALIFORNIA AVE SUITE 103
WAHIAWA HI
96786-1841
US

V. Phone/Fax

Practice location:
  • Phone: 808-621-7733
  • Fax: 808-621-7799
Mailing address:
  • Phone: 808-621-7733
  • Fax: 808-621-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD11212
License Number StateHI

VIII. Authorized Official

Name: DR. JASON TAI PANG LAM
Title or Position: PRESIDENT
Credential: MD
Phone: 808-621-7733