Provider Demographics
NPI:1821723248
Name:COLOMA CABACCANG, GWENDOLYN BUENAVISTA
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:BUENAVISTA
Last Name:COLOMA CABACCANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-820 MOANALUA RD SPC 5-726
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5200
Mailing Address - Country:US
Mailing Address - Phone:808-342-1611
Mailing Address - Fax:808-443-0943
Practice Address - Street 1:98-820 MOANALUA RD SPC 5-726
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5200
Practice Address - Country:US
Practice Address - Phone:808-342-1611
Practice Address - Fax:808-443-0943
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1606814678172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver