Basic Information
Provider Information
NPI: 1396399754
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HAGBLOM
FirstName: WILLIAM
MiddleName: G
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 828 LAULA WAY
Address2:  
City: HONOLULU
State: HI
PostalCode: 968142246
CountryCode: US
TelephoneNumber: 6199727567
FaxNumber:  
Practice Location
Address1: 200 N VINEYARD BLVD # B-120
Address2:  
City: HONOLULU
State: HI
PostalCode: 968173950
CountryCode: US
TelephoneNumber: 8085361015
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/24/2019
LastUpdateDate: 07/24/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X HIY    

No ID Information.


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