Provider Demographics
NPI:1659023455
Name:MIAN, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:MIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1301 PUNCHBOWL ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2499
Mailing Address - Country:US
Mailing Address - Phone:808-691-1000
Mailing Address - Fax:
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2499
Practice Address - Country:US
Practice Address - Phone:808-691-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-1231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant