Provider Demographics
NPI:1679106728
Name:PEDERSEN, CLARK (RN)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:NE
Mailing Address - Zip Code:68824-0430
Mailing Address - Country:US
Mailing Address - Phone:308-485-4258
Mailing Address - Fax:
Practice Address - Street 1:201 HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:NE
Practice Address - Zip Code:68824-2014
Practice Address - Country:US
Practice Address - Phone:308-485-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE72872163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool