Basic Information
Provider Information
NPI: 1003150368
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BREYMAN
FirstName: MANDI
MiddleName: SUE
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 414 ULUNIU ST
Address2:  
City: KAILUA
State: HI
PostalCode: 967342556
CountryCode: US
TelephoneNumber: (808) 523-1600
FaxNumber:  
Practice Location
Address1: 1329 LUSITANA ST STE 202
Address2:  
City: HONOLULU
State: HI
PostalCode: 968132401
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/26/2012
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XAMD765HIY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
363A00000X  N Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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