Basic Information
Provider Information | |||||||||
NPI: | 1912975988 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FUIMAONO | ||||||||
FirstName: | SIOELI | ||||||||
MiddleName: | FIATAU | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2400 PATTERSON ST | ||||||||
Address2: | SUITE 319 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372031562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6159861256 | ||||||||
FaxNumber: | 6153830873 | ||||||||
Practice Location | |||||||||
Address1: | 2400 PATTERSON ST | ||||||||
Address2: | SUITE 319 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372031562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6159861256 | ||||||||
FaxNumber: | 6153830873 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2006 | ||||||||
LastUpdateDate: | 03/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1326 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 1326 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 3060214 | 05 | TN |   | MEDICAID | 4116189 | 01 | TN | BCBS | OTHER |