Provider Demographics
NPI:1497785596
Name:REILLY, SEAN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:M
Last Name:REILLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-170 HUALALAI RD
Mailing Address - Street 2:STE C-110
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1741
Mailing Address - Country:US
Mailing Address - Phone:808-329-9211
Mailing Address - Fax:
Practice Address - Street 1:75-170 HUALALAI RD
Practice Address - Street 2:STE C-110
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1741
Practice Address - Country:US
Practice Address - Phone:808-329-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD183363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAMD183OtherSTATE LICENSE
HIAMD183OtherSTATE LICENSE
HIP32407Medicare UPIN