Provider Demographics
NPI:1740584218
Name:WANDERER, EMAN'ON FEARLESS
Entity type:Individual
Prefix:
First Name:EMAN'ON
Middle Name:FEARLESS
Last Name:WANDERER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NATHANIEL
Other - Middle Name:CORNELIUS
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1841
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1841
Mailing Address - Country:US
Mailing Address - Phone:808-283-3016
Mailing Address - Fax:
Practice Address - Street 1:1390 MILLER ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2493
Practice Address - Country:US
Practice Address - Phone:808-784-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI172V00000X, 106S00000X
CA171M00000X261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)