Active NPI
Carly P Pederson, ATC/R
- Athletic Trainer
- Elk River, MN
National Provider Identifier
1417394297
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 2433
- Practice address
- 18929 149TH St NW
Elk River, MN 55330-8362 - Phone
- (612) 518-7270
- NPI assigned
- Jun 3, 2013
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 2433 | MN | Primary |
Addresses
Primary practice location
18929 149TH St NW
Elk River, MN 55330-8362
Mailing address
516 15TH Ave SE
Room 190
Minneapolis, MN 55455-0130
Phone (612) 518-7270
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1370217600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1619654400000",
"number": "1417394297",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "516 15TH AVE SE",
"address_2": "ROOM 190",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554550130",
"telephone_number": "612-518-7270"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "18929 149TH ST NW",
"city": "ELK RIVER",
"state": "MN",
"postal_code": "553308362",
"telephone_number": "612-518-7270"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSON",
"first_name": "CARLY",
"middle_name": "P",
"credential": "ATC/R",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2013-06-03",
"last_updated": "2021-04-29",
"certification_date": "2021-04-29",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "MN",
"license": "2433",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Elk River, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.