Provider Demographics
NPI:1982771580
Name:PEDERSEN, GEORGE (MPT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 ROOSEVELT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2990
Mailing Address - Country:US
Mailing Address - Phone:360-825-1540
Mailing Address - Fax:360-825-7434
Practice Address - Street 1:553 ROOSEVELT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2990
Practice Address - Country:US
Practice Address - Phone:360-825-1540
Practice Address - Fax:360-825-7434
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8346462Medicaid
WA217000442Medicare UPIN