Healthcare Provider Details

I. General information

NPI: 1750364626
Provider Name (Legal Business Name): KELLIE A FUKUMURA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/23/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35TH MEDICAL GROUP MISAWA AIR BASE
APO WA
96319
US

IV. Provider business mailing address

277 OHUA AVE
HONOLULU HI
96815-3643
US

V. Phone/Fax

Practice location:
  • Phone: 808-779-1513
  • Fax:
Mailing address:
  • Phone: 808-922-4787
  • Fax: 808-922-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-160
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD 160
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: