Basic Information
| Provider Information | |||||||||
| NPI: | 1932752771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATANABE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MS, MPH, RD, CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1597 KAWELOKA ST | ||||||||
| Address2: | |||||||||
| City: | PEARL CITY | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967821516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5955 ZEAMER AVE | ||||||||
| Address2: | |||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995063702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075803205 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2019 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.