Basic Information
| Provider Information | |||||||||
| NPI: | 1053330076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCQUIAO | ||||||||
| FirstName: | MADELYN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMPONG | ||||||||
| OtherFirstName: | MADELYN | ||||||||
| OtherMiddleName: | Y. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4211 WAIALAE AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968165319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087320782 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4211 WAIALAE AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968165319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087320782 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 06/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN-283 | HI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN-283 | HI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 53787102 | 05 | HI | MEDICAID | 0000220160 | 01 | HI | HMSA PROVIDER NUMBER | OTHER |