Provider Demographics
NPI:1114318409
Name:GOCA, MARYAM KHAYAMI
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:KHAYAMI
Last Name:GOCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 ULUNIU ST STE 411
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2544
Mailing Address - Country:US
Mailing Address - Phone:088-263-7203
Mailing Address - Fax:
Practice Address - Street 1:128 LEHUA ST
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786
Practice Address - Country:US
Practice Address - Phone:808-621-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108560363AM0700X
HIAMD-750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical