Provider Demographics
NPI:1801942792
Name:WAKAYAMA, JO (NP)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:WAKAYAMA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JO
Other - Middle Name:
Other - Last Name:DORSCHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3288 MOANALUA RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1469
Mailing Address - Country:US
Mailing Address - Phone:808-432-0000
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:808-432-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-553363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54947002Medicaid
HI0000244095OtherHMSA BILLING NUMBER
HIH56105Medicare PIN
HI54947002Medicaid