Provider Demographics
NPI:1003034828
Name:PEDERSEN, TYLER CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:CHRISTIAN
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 S 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-3328
Mailing Address - Country:US
Mailing Address - Phone:402-731-1193
Mailing Address - Fax:
Practice Address - Street 1:981150 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-1150
Practice Address - Country:US
Practice Address - Phone:402-559-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE5284207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENE5284Medicare UPIN