Provider Demographics
NPI:1265862221
Name:PACIFIC NEPHROLOGY LLC
Entity Type:Organization
Organization Name:PACIFIC NEPHROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN - MEMBER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:LAKKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-244-1444
Mailing Address - Street 1:95 MAUI LANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-244-1444
Mailing Address - Fax:808-244-1445
Practice Address - Street 1:95 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-244-1444
Practice Address - Fax:808-244-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-12546261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54015501Medicaid
HIH100522Medicare PIN
HI54015501Medicaid