Provider Demographics
NPI:1750364626
Name:FUKUMURA, KELLIE A (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:FUKUMURA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 OHUA AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-3643
Mailing Address - Country:US
Mailing Address - Phone:808-922-4787
Mailing Address - Fax:808-922-4950
Practice Address - Street 1:35TH MEDICAL GROUP
Practice Address - Street 2:MISAWA AIR BASE
Practice Address - City:APO
Practice Address - State:WA
Practice Address - Zip Code:96319
Practice Address - Country:US
Practice Address - Phone:808-779-1513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-160363A00000X
HIAMD 160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0251122OtherHMSA
HI497603-01OtherALOHA CARE
HI497603-01Medicaid
HI497603-01OtherALOHA CARE