Provider Demographics
NPI:1952907008
Name:DAUGHERTY, CHASEN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHASEN
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S BERETANIA ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1871
Mailing Address - Country:US
Mailing Address - Phone:808-356-5699
Mailing Address - Fax:
Practice Address - Street 1:1401 S BERETANIA ST STE 102
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1871
Practice Address - Country:US
Practice Address - Phone:808-356-5699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILKJ207X00000X
363AM0700X
HIAMD-1049207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAMD-1049OtherSTATE OF HAWAII