Provider Demographics
NPI:1619502275
Name:PEDERSEN, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 7TH AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9138
Practice Address - Country:US
Practice Address - Phone:715-822-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty