Provider Demographics
NPI:1194968693
Name:PEDERSEN, CARON CONSTANCE (NP-C)
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:CONSTANCE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CARON
Other - Middle Name:C
Other - Last Name:PEDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:290 S ALMA SCHOOL RD
Mailing Address - Street 2:# 5
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7632
Mailing Address - Country:US
Mailing Address - Phone:480-659-5013
Mailing Address - Fax:480-659-2057
Practice Address - Street 1:290 S ALMA SCHOOL RD
Practice Address - Street 2:# 5
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7632
Practice Address - Country:US
Practice Address - Phone:480-659-5013
Practice Address - Fax:480-659-2057
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5882111NI0013X
AZAP7572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65260Medicare PIN