Basic Information
| Provider Information | |||||||||
| NPI: | 1750364626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUKUMURA | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | AMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 OHUA AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968153643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | 8089224950 | ||||||||
| Practice Location | |||||||||
| Address1: | 758 KAPAHULU AVE | ||||||||
| Address2: | A-319 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968161196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | 8089224950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | AMD 160 | HI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 497603-01 | 01 | HI | ALOHA CARE | OTHER | 497603-01 | 05 | HI | MEDICAID | 00A0251122 | 01 | HI | HMSA | OTHER |