1750364626 NPI number — KELLIE A FUKUMURA PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750364626 NPI number — KELLIE A FUKUMURA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUKUMURA
Provider First Name:
KELLIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750364626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
277 OHUA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96815-3643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-922-4787
Provider Business Mailing Address Fax Number:
808-922-4950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
MISAWA AIR BASE
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
96319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-779-1513
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  AMD-160 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: AMD 160 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A0251122 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 497603-01 . This is a "ALOHA CARE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 497603-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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