1114007259 NPI number — MRS. PAMELA MAE PEDERSEN LADC

Table of content: MRS. PAMELA MAE PEDERSEN LADC (NPI 1114007259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114007259 NPI number — MRS. PAMELA MAE PEDERSEN LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSEN
Provider First Name:
PAMELA
Provider Middle Name:
MAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LADC
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:
1114007259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 KUESTER LAKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-382-5356
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
722 S LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68467-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-362-6128
Provider Business Practice Location Address Fax Number:
402-362-7012
Provider Enumeration Date:
10/16/2006

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: 101YA0400X , with the licence number:  326 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 47052851509 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47052851517 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47052851582 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85276 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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