Healthcare Provider Details

I. General information

NPI: 1023469095
Provider Name (Legal Business Name): NICOLE DEREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

IV. Provider business mailing address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

V. Phone/Fax

Practice location:
  • Phone: 808-473-1880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101262955
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: