Provider Demographics
NPI:1891239513
Name:PEDERSEN, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:
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 401
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-0401
Mailing Address - Country:US
Mailing Address - Phone:605-641-6781
Mailing Address - Fax:
Practice Address - Street 1:890 LAZELLE ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1611
Practice Address - Country:US
Practice Address - Phone:605-720-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily