Provider Demographics
NPI:1598851081
Name:PEDERSON, BRADLEY M (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:M
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6224
Mailing Address - Country:US
Mailing Address - Phone:360-457-1772
Mailing Address - Fax:360-457-9320
Practice Address - Street 1:630 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6224
Practice Address - Country:US
Practice Address - Phone:360-457-1772
Practice Address - Fax:360-457-9320
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPPO00000462213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0617810002Medicare NSC