Provider Demographics
NPI:1770027179
Name:PEDERSEN PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:PEDERSEN PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTIONER/FNP
Authorized Official - Prefix:
Authorized Official - First Name:CAREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:602-625-6286
Mailing Address - Street 1:290 S ALMA SCHOOL RD
Mailing Address - Street 2:# 5 A
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7631
Mailing Address - Country:US
Mailing Address - Phone:480-659-5013
Mailing Address - Fax:480-659-2057
Practice Address - Street 1:290 S ALMA SCHOOL RD
Practice Address - Street 2:# 5 A
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7631
Practice Address - Country:US
Practice Address - Phone:480-659-5013
Practice Address - Fax:480-659-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty