MEDICARE: MS. KELLY ANN FUMIE PARK DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2475	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000255364	OTHER	HI	HMSA QUEST PROV. NUMBER
2	0000255364	OTHER	HI	HMSA PROVIDER NUMBER
3	2695487	OTHER	HI	UNIVERSITY HEALTH ALLIANC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073686630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY ANN FUMIE PARK DPT

Provider Business Mailing Address
First Line	:	850 W HIND DR
Second Line	:	SUITE 104 AND 108
City	:	HONOLULU
State	:	HI
Zip	:	96821-1855
Country	:	US
Telephone Number	:	808-373-4787
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 W HIND DR
Second Line	:	SUITE 104 AND 108
City	:	HONOLULU
State	:	HI
Zip	:	96821-1855
Country	:	US
Telephone Number	:	808-373-4787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/09/2007

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