Provider Demographics
NPI:1336814862
Name:PEDERSON, RYAN THOMAS (ARNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 181ST PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-7312
Mailing Address - Country:US
Mailing Address - Phone:509-290-9067
Mailing Address - Fax:
Practice Address - Street 1:5729 181ST PL SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-7312
Practice Address - Country:US
Practice Address - Phone:509-290-9067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61196922363L00000X
WARN60552083163W00000X
WAF06211579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily