Basic Information
| Provider Information | |||||||||
| NPI: | 1457452187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 614 MICHIGAN AVE W | ||||||||
| Address2: | |||||||||
| City: | WALKER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564842276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185477700 | ||||||||
| FaxNumber: | 2185473922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 10554 | MN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | R140359-6 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 337486600 | 05 | MN | MEDICAID | 58G74WA | 01 | MN | BCBS | OTHER |