Provider Demographics
NPI:1952427734
Name:PEDERSEN, REGINA D (PA-C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:D
Last Name:PEDERSEN
Suffix:
Gender:F
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 1:4790 CAUGHLIN PKWY STE 379
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-0907
Mailing Address - Country:US
Mailing Address - Phone:775-323-7828
Mailing Address - Fax:775-348-5809
Practice Address - Street 1:960 CAUGHLIN XING STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89519-0692
Practice Address - Country:US
Practice Address - Phone:775-323-7828
Practice Address - Fax:775-348-5809
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1952427734Medicaid
NV001516008Medicaid
NV291809Medicare ID - Type Unspecified