Active NPI
Kristine J Pederson, PA-C
- Physician Assistant
- Alexandria, MN
National Provider Identifier
1730409319
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 1420
- Practice address
- 610 30TH Ave W
Alexandria, MN 56308-3426 - Phone
- (320) 763-5123
- Fax
- (320) 763-5749
- NPI assigned
- Jun 7, 2010
- 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 |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 1420 | MN | Primary |
Addresses
Primary practice location
610 30TH Ave W
Alexandria, MN 56308-3426
Mailing address
610 30TH Ave W
Alexandria, MN 56308-3426
Phone (320) 763-5123
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730409319 | Medicaid | MN | |
| 1730409319 | Other | MN | BCBS |
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)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1420 | MN | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1275868800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1653004800000",
"number": "1730409319",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "610 30TH AVE W",
"city": "ALEXANDRIA",
"state": "MN",
"postal_code": "563083426",
"telephone_number": "320-763-5123",
"fax_number": "320-763-5749"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "610 30TH AVE W",
"city": "ALEXANDRIA",
"state": "MN",
"postal_code": "563083426",
"telephone_number": "320-763-5123",
"fax_number": "320-763-5749"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSON",
"first_name": "KRISTINE",
"middle_name": "J",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-06-07",
"last_updated": "2022-05-20",
"certification_date": "2022-05-20",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "MN",
"license": "1420",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1730409319",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "1730409319",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Alexandria, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.