Provider Demographics
NPI:1790162980
Name:PANIOLO PEDIATRICS LLC
Entity Type:Organization
Organization Name:PANIOLO PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:COLIN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-887-6543
Mailing Address - Street 1:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-6149
Mailing Address - Country:US
Mailing Address - Phone:808-887-6543
Mailing Address - Fax:
Practice Address - Street 1:64-1032 MAMALAHOA HWY STE 204
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8441
Practice Address - Country:US
Practice Address - Phone:808-887-6543
Practice Address - Fax:808-887-6294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD16732261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care