Provider Demographics
NPI:1528414752
Name:WORK, IAN MATTHEW
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:WORK
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:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-0564
Mailing Address - Country:US
Mailing Address - Phone:503-703-5383
Mailing Address - Fax:
Practice Address - Street 1:82-6065 MAMALAHOA HWY
Practice Address - Street 2:APT A203
Practice Address - City:CAPTAIN COOK
Practice Address - State:HI
Practice Address - Zip Code:96704-0564
Practice Address - Country:US
Practice Address - Phone:808-266-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16-141172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI81-1352841OtherEMPLOYER IDENTIFICATION NUMBER