Provider Demographics
NPI:1598504169
Name:ASUEGA- CLARK, TESSA KL (MT)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:KL
Last Name:ASUEGA- CLARK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-375 OLOLU ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-2411
Mailing Address - Country:US
Mailing Address - Phone:808-798-0596
Mailing Address - Fax:
Practice Address - Street 1:94-673 KUPUOHI ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-5367
Practice Address - Country:US
Practice Address - Phone:808-364-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-17829225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist