Provider Demographics
NPI:1356698302
Name:CHANG, TIMOTHY (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S BERETANIA ST STE 610
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1873
Mailing Address - Country:US
Mailing Address - Phone:808-691-4211
Mailing Address - Fax:
Practice Address - Street 1:1401 S BERETANIA ST STE 610
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1873
Practice Address - Country:US
Practice Address - Phone:808-691-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60303693225100000X
HIPT-3540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0302052OtherL & I
WA0302030OtherL & I
WA0302030OtherL & I
WAG8914383Medicare PIN
WA0302030OtherL & I
WA0302052OtherL & I