Provider Demographics
NPI:1902829773
Name:PEDERSON, JIM P (PA)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:P
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 23RD ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5127
Mailing Address - Country:US
Mailing Address - Phone:307-324-6002
Mailing Address - Fax:
Practice Address - Street 1:606 23RD ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5127
Practice Address - Country:US
Practice Address - Phone:307-324-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY083363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP55726Medicare UPIN