Provider Demographics
NPI:1184398869
Name:MIKAMI, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MIKAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-108 HALOKO PL
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3922
Mailing Address - Country:US
Mailing Address - Phone:808-291-5128
Mailing Address - Fax:
Practice Address - Street 1:46-005 KAWA ST STE 211
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3838
Practice Address - Country:US
Practice Address - Phone:808-235-6818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-5234-0225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist