Provider Demographics
NPI:1316449358
Name:WAKUMOTO, TIFFANY K (DPT)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:K
Last Name:WAKUMOTO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:K
Other - Last Name:IKEDA-SIMAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:P.O. BOX 288
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766
Mailing Address - Country:US
Mailing Address - Phone:808-632-0033
Mailing Address - Fax:808-632-0077
Practice Address - Street 1:3088 AUKELE STREET
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766
Practice Address - Country:US
Practice Address - Phone:808-632-0033
Practice Address - Fax:808-632-0077
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-4520208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI83776Medicaid