Provider Demographics
NPI:1568444941
Name:MILLARD, SHANE J (AMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:J
Last Name:MILLARD
Suffix:
Gender:M
Credentials:AMD
Other - Prefix:
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Mailing Address - Street 1:130 KAILUA RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3420
Mailing Address - Country:US
Mailing Address - Phone:808-261-4411
Mailing Address - Fax:808-261-3322
Practice Address - Street 1:130 KAILUA RD
Practice Address - Street 2:SUITE 111
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3420
Practice Address - Country:US
Practice Address - Phone:808-261-4411
Practice Address - Fax:808-466-3354
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-05-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
HIAMD 240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56774501Medicaid
HI56774501OtherALOHA CARE
HI0000250415OtherHMSA