Provider Demographics
NPI:1912479213
Name:WILKES, JAMES CLINTON III
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CLINTON
Last Name:WILKES
Suffix:III
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 1:2401 KIPUKA ST
Mailing Address - Street 2:
Mailing Address - City:KOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96756-9555
Mailing Address - Country:US
Mailing Address - Phone:808-634-4770
Mailing Address - Fax:
Practice Address - Street 1:3-1866 KAUMUALII HWY
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-8606
Practice Address - Country:US
Practice Address - Phone:808-634-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11801225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
818335OtherABMP