Provider Demographics
NPI:1407466436
Name:PEDERSEN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 CAVELL AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2317
Mailing Address - Country:US
Mailing Address - Phone:612-598-1435
Mailing Address - Fax:
Practice Address - Street 1:6452 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3245
Practice Address - Country:US
Practice Address - Phone:952-999-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7578363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily