Healthcare Provider Details

I. General information

NPI: 1669792339
Provider Name (Legal Business Name): DAVID J. PEDERSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 PAA ST
HONOLULU HI
96819-4430
US

IV. Provider business mailing address

2828 PAA ST
HONOLULU HI
96819-4430
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-5700
  • Fax:
Mailing address:
  • Phone: 808-432-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113570
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-1332
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: