MEDICARE: ANDREW CLARK SOBREPENA RN

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN-114502	HI

General Provider Information

NPI Number	:	1306677166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW CLARK SOBREPENA RN

Provider Business Mailing Address
First Line	:	444 HOBRON LN PH 1
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96815-1231
Country	:	US
Telephone Number	:	808-862-8795
Fax Number	:	808-977-4417

Provider Business Practice Location Address
First Line	:	444 HOBRON LN PH 1
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96815-1231
Country	:	US
Telephone Number	:	808-862-8795
Fax Number	:	808-977-4417

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

Provider Enumeration Date	:	08/12/2024
Last Update Date	:	05/25/2026

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