Provider Demographics
NPI:1215581913
Name:PEDERSON, GARY DUANE
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DUANE
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DEER TRL NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-1110
Mailing Address - Country:US
Mailing Address - Phone:423-331-0501
Mailing Address - Fax:
Practice Address - Street 1:111 DEER TRL NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-1110
Practice Address - Country:US
Practice Address - Phone:423-331-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider