Basic Information
Provider Information | |||||||||
NPI: | 1508336694 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARR | ||||||||
FirstName: | KRISTA | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45-637 HALEKOU RD | ||||||||
Address2: |   | ||||||||
City: | KANEOHE | ||||||||
State: | HI | ||||||||
PostalCode: | 967441715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7604496552 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 45-955 KAMEHAMEHA HWY # 404-405 | ||||||||
Address2: |   | ||||||||
City: | KANEOHE | ||||||||
State: | HI | ||||||||
PostalCode: | 967443222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8082472973 | ||||||||
FaxNumber: | 8084273472 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2018 | ||||||||
LastUpdateDate: | 11/30/2018 | ||||||||
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 | 106E00000X |   |   | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 0000000 | 01 |   | TRI-CARE | OTHER |