Provider Demographics
NPI:1730587528
Name:PEDERSEN, KERRY (PA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3025
Practice Address - Fax:952-993-1937
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2021-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN11795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant