Provider Demographics
NPI:1972536373
Name:OTTOSEN, PERNILLE
Entity Type:Individual
Prefix:
First Name:PERNILLE
Middle Name:
Last Name:OTTOSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 KAPAHULU AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-3850
Mailing Address - Country:US
Mailing Address - Phone:808-735-0007
Mailing Address - Fax:
Practice Address - Street 1:449 KAPAHULU AVE STE 104
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-3850
Practice Address - Country:US
Practice Address - Phone:808-735-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60463242207Q00000X
HIMD19692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN648718100Medicaid
MN648718100Medicaid
MN080007069Medicare PIN