Provider Demographics
NPI:1003327487
Name:PEDIGO, ELISE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:PEDIGO
Suffix:
Gender:F
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 1:3864 MASTHEAD ST NE UNIT E2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4479
Mailing Address - Country:US
Mailing Address - Phone:505-356-4178
Mailing Address - Fax:
Practice Address - Street 1:630 HAINES AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1226
Practice Address - Country:US
Practice Address - Phone:505-268-5611
Practice Address - Fax:505-268-5736
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AM0700X
NMPA2017-0099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant