Basic Information
| Provider Information | |||||||||
| NPI: | 1174518955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANIS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 JARRETT WHITE RD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER, ATTN MCHK-QS | ||||||||
| City: | TAMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 JARRETT WHITE RD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER, ATTN MCHK-QS | ||||||||
| City: | TAMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 30001 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207SG0201X | 30001 | IA | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 0116129 | 05 | IA | MEDICAID | 17019 | 01 | IA | WELLMARK BCBS | OTHER |