Basic Information
| Provider Information | |||||||||
| NPI: | 1760566913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKELS | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERZINSKI | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | K. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 46-056 KAMEHAMEHA HWY | ||||||||
| Address2: | SUITE 221 | ||||||||
| City: | KANEOHE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967443755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082336200 | ||||||||
| FaxNumber: | 8082336255 | ||||||||
| Practice Location | |||||||||
| Address1: | 46-056 KAMEHAMEHA HWY | ||||||||
| Address2: | SUITE 221 | ||||||||
| City: | KANEOHE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967443755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082336200 | ||||||||
| FaxNumber: | 8082336255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-13156 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0000253914 | 01 | HI | HMSA | OTHER | 9158444 | 01 | HI | UHA | OTHER | 569618 01 | 05 | HI | MEDICAID |