Provider Demographics
NPI:1750680369
Name:WATANABE, LIANE JUNKO (DPM)
Entity Type:Individual
Prefix:
First Name:LIANE
Middle Name:JUNKO
Last Name:WATANABE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:LIANE
Other - Middle Name:JUNKO
Other - Last Name:WATANABE-LIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1245 KUALA ST STE 102A
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3900
Mailing Address - Country:US
Mailing Address - Phone:808-726-2161
Mailing Address - Fax:808-726-2163
Practice Address - Street 1:1245 KUALA ST STE 102A
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3900
Practice Address - Country:US
Practice Address - Phone:808-726-2161
Practice Address - Fax:808-726-2163
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPO-196213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI79310Medicaid
HIPO-196OtherDPM