Provider Demographics
NPI:1730278037
Name:PEDERSON, KIM R (MHS PA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MHS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9542
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1712
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10200363A00000X
MEPA1356363AM0700X, 363AM0700X
WAPA60511027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41952400Medicaid
WI41952400Medicaid