Basic Information
| Provider Information | |||||||||
| NPI: | 1043396096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEN | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WON | ||||||||
| OtherFirstName: | AIDA | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 677 ALA MOANA BLVD | ||||||||
| Address2: | SUITE 1001 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968135419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085238461 | ||||||||
| FaxNumber: | 8085355976 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 N. KUAKINI STREET | ||||||||
| Address2: | HPM-9 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085238461 | ||||||||
| FaxNumber: | 8085281897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD13886 | HI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 585979-01 | 05 | HI | MEDICAID |