Provider Demographics
NPI:1508304387
Name:PETAIA-STEFFANY, LALOASI MIKA (OD)
Entity Type:Individual
Prefix:
First Name:LALOASI
Middle Name:MIKA
Last Name:PETAIA-STEFFANY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4779
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-4779
Mailing Address - Country:US
Mailing Address - Phone:684-770-3532
Mailing Address - Fax:684-633-6333
Practice Address - Street 1:4779 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799-4779
Practice Address - Country:US
Practice Address - Phone:684-770-3532
Practice Address - Fax:684-633-6333
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS2216 A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS660813927OtherEIN#