Provider Demographics
NPI:1326622739
Name:PEDERSON, VANESSA (BADO, BSO)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:BADO, BSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 S GARNETT RD STE 302
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5218
Mailing Address - Country:US
Mailing Address - Phone:918-664-6544
Mailing Address - Fax:918-664-0668
Practice Address - Street 1:4606 S GARNETT RD STE 302
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5218
Practice Address - Country:US
Practice Address - Phone:918-664-6544
Practice Address - Fax:918-664-0668
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist