Provider Demographics
NPI:1578097465
Name:WANDASAN, HENANINOOEKAWAHINEUI
Entity Type:Individual
Prefix:
First Name:HENANINOOEKAWAHINEUI
Middle Name:
Last Name:WANDASAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAWAHINE
Other - Middle Name:
Other - Last Name:WANDASAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 W KAWILI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W KAWILI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4075
Practice Address - Country:US
Practice Address - Phone:808-932-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIXLQ0000591693Medicaid