1730852609 NPI number — CASSANDRA ELIZABETH PEDERSEN RD

Table of content: CASSANDRA ELIZABETH PEDERSEN RD (NPI 1730852609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730852609 NPI number — CASSANDRA ELIZABETH PEDERSEN RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSEN
Provider First Name:
CASSANDRA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730852609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 W SAINT GERMAIN STREET
Provider Second Line Business Mailing Address:
2ND & 3RD FLOOR
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56301-3633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-486-8335
Provider Business Mailing Address Fax Number:
763-343-6112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 W SAINT GERMAIN STREET
Provider Second Line Business Practice Location Address:
2ND & 3RD FLOOR
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56301-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-486-8335
Provider Business Practice Location Address Fax Number:
763-343-6112
Provider Enumeration Date:
07/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  3902 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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