Provider Demographics
NPI:1457452187
Name:PEDERSON, AMANDA (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:
Practice Address - Street 1:614 MICHIGAN AVE W
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-2276
Practice Address - Country:US
Practice Address - Phone:218-547-7700
Practice Address - Fax:218-547-3922
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10554163W00000X
MNR140359-6363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN337486600Medicaid
MN58G74WAOtherBCBS
MN337486600Medicaid