Provider Demographics
NPI:1659093342
Name:IKARI, TED MASAO (CRNA)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:MASAO
Last Name:IKARI
Suffix:
Gender:M
Credentials:CRNA
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 129
Mailing Address - Street 2:
Mailing Address - City:HONOMU
Mailing Address - State:HI
Mailing Address - Zip Code:96728-0129
Mailing Address - Country:US
Mailing Address - Phone:808-255-4455
Mailing Address - Fax:
Practice Address - Street 1:2575 NORTHWINDS PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2232
Practice Address - Country:US
Practice Address - Phone:808-255-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145029367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered