Provider Demographics
NPI:1386866234
Name:PEDERSEN, JAN (BOCO ORTHOTIST)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:BOCO ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-2000
Mailing Address - Country:US
Mailing Address - Phone:518-674-3361
Mailing Address - Fax:518-674-8320
Practice Address - Street 1:23 ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12196-2000
Practice Address - Country:US
Practice Address - Phone:518-674-3361
Practice Address - Fax:518-674-8320
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01755577Medicaid
NY4483480001Medicare NSC