Provider Demographics
NPI:1245046903
Name:PEDERSON, JUSTIN (RN, AGACNP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:RN, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BOX ST APT N233
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-5586
Mailing Address - Country:US
Mailing Address - Phone:425-458-8947
Mailing Address - Fax:
Practice Address - Street 1:424 E 34TH ST FL 16
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4901
Practice Address - Country:US
Practice Address - Phone:646-929-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433062363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care