Provider Demographics
NPI:1558981688
Name:WALLACE, AARON SCHUYLER
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:SCHUYLER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 KANOA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-5816
Mailing Address - Country:US
Mailing Address - Phone:808-244-5999
Mailing Address - Fax:808-244-1295
Practice Address - Street 1:71 KANOA ST STE 101
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-5816
Practice Address - Country:US
Practice Address - Phone:808-244-5999
Practice Address - Fax:808-244-1295
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.076044207Y00000X
390200000X
HIMD-25250207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program