Provider Demographics
NPI:1487623369
Name:JOHANSEN, KAZUE T (PA)
Entity type:Individual
Prefix:MS
First Name:KAZUE
Middle Name:T
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1625
Mailing Address - Country:US
Mailing Address - Phone:808-984-7419
Mailing Address - Fax:
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1625
Practice Address - Country:US
Practice Address - Phone:808-984-7419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPA000064363AM0700X
HIAMD421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUQ52302Medicare UPIN