Provider Demographics
NPI:1376143552
Name:QUEJA, ROMAN
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:QUEJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 E KAUAI ST
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2940
Mailing Address - Country:US
Mailing Address - Phone:808-214-7274
Mailing Address - Fax:808-214-5081
Practice Address - Street 1:58 E KAUAI ST
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2940
Practice Address - Country:US
Practice Address - Phone:808-214-7274
Practice Address - Fax:808-214-5081
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist