Provider Demographics
NPI:1376861146
Name:PEDERSON, ANGELA (MT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON AVE N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON AVE N
Practice Address - Street 2:SUITE 202
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1330
Practice Address - Country:US
Practice Address - Phone:612-455-2920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist