Provider Demographics
NPI:1265419022
Name:PEDERSEN, KATHY JANE (PA-C, MPAS)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:JANE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 S 3200 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2822
Mailing Address - Country:US
Mailing Address - Phone:801-964-6214
Mailing Address - Fax:801-412-6950
Practice Address - Street 1:4745 S 3200 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2822
Practice Address - Country:US
Practice Address - Phone:801-964-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102701-1206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine