Basic Information
| Provider Information | |||||||||
| NPI: | 1730409319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1420 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1730409319 | 05 | MN | MEDICAID | 1730409319 | 01 | MN | BCBS | OTHER |