Provider Demographics
NPI:1578878187
Name:PEDERSEN, ALESHA J (PA)
Entity Type:Individual
Prefix:MS
First Name:ALESHA
Middle Name:J
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LYON PL STE 303
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2546
Mailing Address - Country:US
Mailing Address - Phone:315-713-6700
Mailing Address - Fax:866-816-0815
Practice Address - Street 1:3 LYON PL STE 303
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2546
Practice Address - Country:US
Practice Address - Phone:315-713-6700
Practice Address - Fax:866-816-0815
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02901363AM0700X
NY014198363AM0700X
NYP76871363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03272608Medicaid
NYJ400045658/GP 70008AMedicare PIN
NYJ400027499/GP BA0017Medicare PIN