Provider Demographics
NPI:1164792081
Name:PEDERSEN, ANNE MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MICHELLE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CONCORD PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6991
Mailing Address - Country:US
Mailing Address - Phone:210-804-5400
Mailing Address - Fax:
Practice Address - Street 1:601 CREEKSIDE XING STE 106
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4093
Practice Address - Country:US
Practice Address - Phone:210-630-4637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8793225100000X
TX11043052251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ152354Medicare PIN
AZZ169257Medicare PIN