Provider Demographics
NPI:1912434036
Name:PEDERSEN, ERIC SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:SCOTT
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7539
Mailing Address - Country:US
Mailing Address - Phone:603-225-2711
Mailing Address - Fax:603-224-6527
Practice Address - Street 1:250 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7539
Practice Address - Country:US
Practice Address - Phone:603-225-2711
Practice Address - Fax:603-224-6527
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550031341363A00000X
NH1321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant