Provider Demographics
NPI:1174104566
Name:GONGOB, BAILEY R
Entity type:Individual
Prefix:MISS
First Name:BAILEY
Middle Name:R
Last Name:GONGOB
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 1:335 ANAPALAU ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-2241
Mailing Address - Country:US
Mailing Address - Phone:808-294-9728
Mailing Address - Fax:
Practice Address - Street 1:771 AMANA ST STE 201
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3238
Practice Address - Country:US
Practice Address - Phone:808-294-9728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program