Provider Demographics
NPI:1265965321
Name:PHANHTHARATH, PHYLAVANH (ACNS-BC)
Entity type:Individual
Prefix:MS
First Name:PHYLAVANH
Middle Name:
Last Name:PHANHTHARATH
Suffix:
Gender:F
Credentials:ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 WAIANUENUE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2094
Mailing Address - Country:US
Mailing Address - Phone:808-932-3000
Mailing Address - Fax:
Practice Address - Street 1:1190 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2094
Practice Address - Country:US
Practice Address - Phone:808-932-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-2756364SA2200X
TXAP133384283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health