Provider Demographics
NPI:1669792339
Name:PEDERSEN, DAVID J (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 PAA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4430
Mailing Address - Country:US
Mailing Address - Phone:808-432-5700
Mailing Address - Fax:
Practice Address - Street 1:2828 PAA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4430
Practice Address - Country:US
Practice Address - Phone:808-432-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113570363AM0700X, 363AM0700X
HIAMD-1332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty