Provider Demographics
NPI:1972854099
Name:KANEDA, TIM TAIKYO (PA-C, MHS)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:TAIKYO
Last Name:KANEDA
Suffix:
Gender:M
Credentials:PA-C, MHS
Other - Prefix:
Other - First Name:TAIKYO
Other - Middle Name:
Other - Last Name:KANEDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:180 DICKENSON ST
Mailing Address - Street 2:STE 103
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-1215
Mailing Address - Country:US
Mailing Address - Phone:808-214-5985
Mailing Address - Fax:808-214-6766
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:808-242-4267
Practice Address - Fax:808-242-4292
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD 480363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical