Provider Demographics
NPI:1093758716
Name:PEDERSEN, GERALD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 HYACINTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-2933
Mailing Address - Country:US
Mailing Address - Phone:225-389-2928
Mailing Address - Fax:225-389-2931
Practice Address - Street 1:6300 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4037
Practice Address - Country:US
Practice Address - Phone:225-658-4000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59521Medicare ID - Type Unspecified