Provider Demographics
NPI:1346299435
Name:LY, MICKI N (MD)
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:N
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3010
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96733-3010
Mailing Address - Country:US
Mailing Address - Phone:808-877-6526
Mailing Address - Fax:808-871-6701
Practice Address - Street 1:89 HOOKELE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3513
Practice Address - Country:US
Practice Address - Phone:808-877-6526
Practice Address - Fax:808-871-6701
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 12031207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI508161Medicaid
HIH09822Medicare UPIN