Provider Demographics
NPI:1992758015
Name:VICERRA-JAENA, MACRINA U (APRN)
Entity type:Individual
Prefix:
First Name:MACRINA
Middle Name:U
Last Name:VICERRA-JAENA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-896 MAKULE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2526
Mailing Address - Country:US
Mailing Address - Phone:808-689-4414
Mailing Address - Fax:808-689-7115
Practice Address - Street 1:91-896 MAKULE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2526
Practice Address - Country:US
Practice Address - Phone:808-689-4414
Practice Address - Fax:808-689-7115
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN 455363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH54603OtherMEDICARE PROVIDER NUMBER
HIH54601OtherMEDICARE PROVIDER NUMBER
HIH54601OtherMEDICARE PROVIDER NUMBER