Provider Demographics
NPI:1093203861
Name:PEDERSEN, CARRIE (FNP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MUNICIPAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-3703
Mailing Address - Country:US
Mailing Address - Phone:903-713-1574
Mailing Address - Fax:903-713-1589
Practice Address - Street 1:100 MUNICIPAL DR STE 300
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-3703
Practice Address - Country:US
Practice Address - Phone:903-713-1574
Practice Address - Fax:903-713-1589
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily