Healthcare Provider Details

I. General information

NPI: 1932709219
Provider Name (Legal Business Name): BRAYDEN CARL PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPAA QUARRY PLACE
KAILUA HI
96734
US

IV. Provider business mailing address

147 JUSTICIA PL
HONOLULU HI
96818-1288
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 469-919-9348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: