Healthcare Provider Details

I. General information

NPI: 1396204384
Provider Name (Legal Business Name): JAYMIE ANDAYA BALIWAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 MAIN ST
WAILUKU HI
96793-1666
US

IV. Provider business mailing address

2180 MAIN ST
WAILUKU HI
96793-1666
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-6464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-27256
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: