Provider Demographics
NPI:1407411192
Name:BRODERSEN, SAGE NAOMI (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:NAOMI
Last Name:BRODERSEN
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 WAIOMAO RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3430
Mailing Address - Country:US
Mailing Address - Phone:808-940-3345
Mailing Address - Fax:
Practice Address - Street 1:2747 WAIOMAO RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3429
Practice Address - Country:US
Practice Address - Phone:808-940-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1222171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist