Healthcare Provider Details

I. General information

NPI: 1780386375
Provider Name (Legal Business Name): ALYSSA SUI GEEN MIYASATO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE FL 5
BOSTON MA
02118-2309
US

IV. Provider business mailing address

1329 LUSITANA ST STE 802
HONOLULU HI
96813-2434
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-6840
  • Fax: 617-414-6710
Mailing address:
  • Phone: 617-414-6840
  • Fax: 617-414-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number1780386375
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number1780386375
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1780386375
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1780386375
License Number StateHI
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1780386375
License Number StateHI
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1780386375
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: