Provider Demographics
NPI:1801994843
Name:PEDERSON, MARK (LP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MARTY DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-682-5420
Mailing Address - Fax:763-682-5803
Practice Address - Street 1:102 MARTY DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-682-5420
Practice Address - Fax:763-682-5803
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2544103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110563OtherUCARE
MNHP18919OtherHEALTHPARTNERS
MN62-20079OtherMEDICA
MN67D66PEOtherBLUE CROSS BLUE SHIELD
MN1000260OtherPREFERRED ONE