Provider Demographics
NPI:1518979871
Name:MYRIANTHIS, NICOLAS (PT)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:
Last Name:MYRIANTHIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 ALAWAENA ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3506
Mailing Address - Country:US
Mailing Address - Phone:808-959-0877
Mailing Address - Fax:
Practice Address - Street 1:15-2866 GOVERNMENT MAIN ROAD
Practice Address - Street 2:PAHOA VILLAGE CENTER
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-965-0880
Practice Address - Fax:808-965-0770
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01025102Medicaid
HID10639OtherHMSA PAHOA
HI01025101Medicaid
HIA10635OtherHMSA MAIN
HIH0000CBBCWMedicare PIN