Provider Demographics
NPI:1730409319
Name:PEDERSON, KRISTINE J (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:J
Last Name:PEDERSON
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 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-5749
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-5749
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1730409319Medicaid
MN1730409319OtherBCBS
MN1730409319Medicare NSC