Basic Information
| Provider Information | |||||||||
| NPI: | 1982055851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOM | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | MBBS, MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLERTON | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79-1019 HAUKAPILA ST | ||||||||
| Address2: | |||||||||
| City: | KEALAKEKUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967507920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083229311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 79-1019 HAUKAPILA ST | ||||||||
| Address2: | |||||||||
| City: | KEALAKEKUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967507920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083229311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 21094 | HI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.