Basic Information
| Provider Information | |||||||||
| NPI: | 1730739806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISHIMOTO | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95-092 KAWAU ST | ||||||||
| Address2: | |||||||||
| City: | MILILANI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967891512 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 203 KAPAA QUARRY PL | ||||||||
| Address2: | #5002 | ||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087412232 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2019 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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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 | 106S00000X | Y |
No ID Information.