Provider Demographics
NPI:1366657884
Name:HACHIYA, KIYOMI ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIYOMI
Middle Name:ANNE
Last Name:HACHIYA
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 1:1978 HIGHLAND PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1351
Mailing Address - Country:US
Mailing Address - Phone:651-699-9814
Mailing Address - Fax:
Practice Address - Street 1:6440 SOUTH MILLROCK DRIVE SUITE 175
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:800-328-3075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093549208000000X
MN26809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND83763Medicare UPIN