Provider Demographics
NPI:1598064677
Name:MARTIN, KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S BERETANIA ST STE 750
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1881
Mailing Address - Country:US
Mailing Address - Phone:808-686-4010
Mailing Address - Fax:
Practice Address - Street 1:1401 S BERETANIA ST STE 750
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1881
Practice Address - Country:US
Practice Address - Phone:808-686-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant