Provider Demographics
NPI:1033885504
Name:PEDERSON, SAMANTHA ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELLEN
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:E
Other - Last Name:BOARDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5200 S 56TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-1891
Mailing Address - Country:US
Mailing Address - Phone:402-421-6200
Mailing Address - Fax:402-421-6070
Practice Address - Street 1:5200 S 56TH ST STE 2
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-1891
Practice Address - Country:US
Practice Address - Phone:402-421-6200
Practice Address - Fax:402-421-6070
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2565207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine