Provider Demographics
NPI:1801041801
Name:LUM, ETHAN (ATC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-149 PUAALII ST
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-2205
Mailing Address - Country:US
Mailing Address - Phone:808-780-1564
Mailing Address - Fax:
Practice Address - Street 1:3142 WAIALAE AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-1510
Practice Address - Country:US
Practice Address - Phone:808-739-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer