Provider Demographics
NPI:1861236432
Name:PENGSON, EDWIN LIBUNAO
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:LIBUNAO
Last Name:PENGSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1007 HIAPO ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3709
Mailing Address - Country:US
Mailing Address - Phone:808-797-5970
Mailing Address - Fax:
Practice Address - Street 1:94-1007 HIAPO ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3709
Practice Address - Country:US
Practice Address - Phone:808-797-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-220030253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency