Provider Demographics
NPI:1336550979
Name:PEDERSON, THERESE B M (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:B M
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:BEAU-MARGARET
Other - Last Name:NAUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:916 SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-2813
Mailing Address - Country:US
Mailing Address - Phone:952-442-2191
Mailing Address - Fax:
Practice Address - Street 1:916 SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-2813
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant