Provider Demographics
NPI:1780147074
Name:FONSECA, RANDY BRYAN
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:BRYAN
Last Name:FONSECA
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:PO BOX 2018
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:HI
Mailing Address - Zip Code:96785-2018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 HINANO ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4427
Practice Address - Country:US
Practice Address - Phone:808-589-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker