Provider Demographics
NPI:1093104952
Name:KOSOMBOON, WITSUDAR (RN)
Entity type:Individual
Prefix:MRS
First Name:WITSUDAR
Middle Name:
Last Name:KOSOMBOON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:WITSUDAR
Other - Middle Name:
Other - Last Name:PHOTHINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:459 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1522
Mailing Address - Country:US
Mailing Address - Phone:808-481-2448
Mailing Address - Fax:808-680-0003
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:808-458-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-56666163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse