Provider Demographics
NPI:1326359050
Name:PEDERSEN, RICHARD WALDEMAR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WALDEMAR
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 1:2120 N 57TH WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3827
Mailing Address - Country:US
Mailing Address - Phone:954-966-0721
Mailing Address - Fax:
Practice Address - Street 1:2120 N 57TH WAY
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3827
Practice Address - Country:US
Practice Address - Phone:954-966-0721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1449122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered