Provider Demographics
NPI:1508147224
Name:PEDERSON, JANE CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:CAROL
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9478 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9304
Mailing Address - Country:US
Mailing Address - Phone:651-730-9471
Mailing Address - Fax:
Practice Address - Street 1:9478 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9304
Practice Address - Country:US
Practice Address - Phone:651-730-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32722207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E19393Medicare UPIN