1699870956 NPI number — PATTI K.M. ENDO M.D.

Table of content: JENNIFER ANNE DIETTMAN LAPC, ATR-P (NPI 1881579399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699870956 NPI number — PATTI K.M. ENDO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENDO
Provider First Name:
PATTI
Provider Middle Name:
K.M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1699870956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 WELLS ST
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
WAILUKU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96793-2365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-877-3635
Provider Business Mailing Address Fax Number:
808-877-4363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 WELLS ST 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAILUKU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96793-2365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-877-3635
Provider Business Practice Location Address Fax Number:
808-877-4363
Provider Enumeration Date:
09/13/2006

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: 207N00000X , with the licence number:  MD 9088 , 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: 07506301 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: B202107 . This is a "BCBS" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".