Provider Demographics
NPI:1407404387
Name:CHUA, LYRA FUMIKO RONQUILLO
Entity Type:Individual
Prefix:
First Name:LYRA FUMIKO
Middle Name:RONQUILLO
Last Name:CHUA
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 1:4955 HANAWAI ST APT 9-104
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-8818
Mailing Address - Country:US
Mailing Address - Phone:707-386-2843
Mailing Address - Fax:
Practice Address - Street 1:55 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:808-243-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2736363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner