Basic Information
| Provider Information | |||||||||
| NPI: | 1164633954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANAYAMA-TRIVEDI | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | JBPHH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084734411 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | JBPHH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084734411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 202089 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1092479 | 05 | LA | MEDICAID |