Provider Demographics
NPI:1437868353
Name:GASHWYTEWA, MICHAEL ALEXANDER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:GASHWYTEWA
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 1:41-1420 KUHIMANA ST
Mailing Address - Street 2:
Mailing Address - City:WAIMANALO
Mailing Address - State:HI
Mailing Address - Zip Code:96795-1220
Mailing Address - Country:US
Mailing Address - Phone:480-204-4154
Mailing Address - Fax:
Practice Address - Street 1:41-1420 KUHIMANA ST
Practice Address - Street 2:
Practice Address - City:WAIMANALO
Practice Address - State:HI
Practice Address - Zip Code:96795-1220
Practice Address - Country:US
Practice Address - Phone:480-204-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI686234106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI9809496Medicaid