Provider Demographics
NPI:1497201396
Name:THONGKOPPHET, AWATSADA
Entity Type:Individual
Prefix:
First Name:AWATSADA
Middle Name:
Last Name:THONGKOPPHET
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 1:1088 BISHOP ST
Mailing Address - Street 2:APT 805
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-3141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98-027 HEKAHA ST
Practice Address - Street 2:BUILDING 3 UNIT 21
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4910
Practice Address - Country:US
Practice Address - Phone:808-457-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI12849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist