Provider Demographics
NPI:1578771747
Name:PEDERSEN, MEGAN ANN (CPNP)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:ANN
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 BROOKDALE ST STE C
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4543
Mailing Address - Country:US
Mailing Address - Phone:276-666-7545
Mailing Address - Fax:
Practice Address - Street 1:1109 BROOKDALE ST STE C
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4543
Practice Address - Country:US
Practice Address - Phone:276-666-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236844363LP0200X
SC17579363L00000X
VA0024170259363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner