Basic Information
| Provider Information | |||||||||
| NPI: | 1134482755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75-5751 KUAKINI HWY STE 203 | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967401753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083333600 | ||||||||
| FaxNumber: | 8089615167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1178 KINOOLE ST | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967207206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0833383600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007618 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 3540 | HI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7100215240 | 05 | KY | MEDICAID | 000000781639 | 01 | KY | BCBS WALMART MILLE | OTHER | P01105256 | 01 | KY | RR MEDICARE-BAPTIST HEALTH MADISONVILLE INC | OTHER | 000000781754 | 01 | KY | BCBS TROVER | OTHER | 3540 | 01 | HI | APRN LICENSE | OTHER |