Provider Demographics
NPI:1659368405
Name:PEDERSEN, SUSAN C (ACNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:C
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 AIRPORT EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5238
Mailing Address - Country:US
Mailing Address - Phone:845-262-5313
Mailing Address - Fax:845-262-5330
Practice Address - Street 1:327 ROUTE 59
Practice Address - Street 2:
Practice Address - City:AIRMONT
Practice Address - State:NY
Practice Address - Zip Code:10952
Practice Address - Country:US
Practice Address - Phone:845-356-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321489363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP33251Medicaid
NYP33251Medicaid
NY2E2741Medicare PIN