Provider Demographics
NPI:1679247480
Name:ANDRADE, DALLAS R
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:R
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DALLAS
Other - Middle Name:R
Other - Last Name:GARBETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:75-184 HUALALAI RD STE 202
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1719
Mailing Address - Country:US
Mailing Address - Phone:808-329-8251
Mailing Address - Fax:808-334-0130
Practice Address - Street 1:75-184 HUALALAI RD STE 202
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1719
Practice Address - Country:US
Practice Address - Phone:808-329-8251
Practice Address - Fax:808-334-0130
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3269363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI001824Medicaid