Provider Demographics
NPI:1053777342
Name:ACOSTA, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-127 LUNAPULE RD STE 7E
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2119
Mailing Address - Country:US
Mailing Address - Phone:808-640-2660
Mailing Address - Fax:
Practice Address - Street 1:75-5995 KUAKINI HWY STE 513
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2124
Practice Address - Country:US
Practice Address - Phone:808-365-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-03
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-1055363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAMD-1055OtherHAWAII PA LICENSE