Provider Demographics
NPI:1720605504
Name:KEANUENUE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:KEANUENUE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAIPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-372-2477
Mailing Address - Street 1:707 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-2213
Mailing Address - Country:US
Mailing Address - Phone:808-372-2477
Mailing Address - Fax:
Practice Address - Street 1:615 PIIKOI ST STE 1501
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3142
Practice Address - Country:US
Practice Address - Phone:808-600-2180
Practice Address - Fax:808-600-2199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI688989Medicaid