Provider Demographics
NPI:1437354453
Name:PEDERSEN, RYAN (LAC, DOM)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:LAC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8783 WEST HACKAMORE DRIVE
Mailing Address - Street 2:SUITE #8
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-376-7172
Mailing Address - Fax:208-376-4778
Practice Address - Street 1:8783 WEST HACKAMORE DRIVE
Practice Address - Street 2:SUITE #8
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-376-7172
Practice Address - Fax:208-376-4778
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-119171100000X
IDNM 831171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010150868Medicare UPIN
IDNCBL1Medicare UPIN