Provider Demographics
NPI:1134599210
Name:PEDERSEN, SARAH ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:MAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3107 FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2956
Mailing Address - Country:US
Mailing Address - Phone:816-935-9422
Mailing Address - Fax:816-364-2575
Practice Address - Street 1:5301 FARAON ST
Practice Address - Street 2:C
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3512
Practice Address - Country:US
Practice Address - Phone:816-437-8122
Practice Address - Fax:816-407-9609
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015034091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant