Provider Demographics
NPI:1669781381
Name:PEDERSON, ERIN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MARIE
Other - Last Name:JUNGELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-529-4687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1669781381Medicaid
MN970005052Medicare PIN