Provider Demographics
NPI:1780352914
Name:WILSON, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:WILSON
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 1:1226 YOUNG ST APT H
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1810
Mailing Address - Country:US
Mailing Address - Phone:808-269-2237
Mailing Address - Fax:808-400-5892
Practice Address - Street 1:1226 YOUNG ST APT H
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1810
Practice Address - Country:US
Practice Address - Phone:808-269-2237
Practice Address - Fax:808-400-5892
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI171000000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No171000000XOther Service ProvidersMilitary Health Care Provider