Provider Demographics
NPI:1306425970
Name:PEDERSEN, ALEXIS DIANNE (PA C)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:DIANNE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 GRAND CENTRAL AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2902 W AGUA FRIA FWY STE 1000
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3969
Practice Address - Country:US
Practice Address - Phone:623-582-6420
Practice Address - Fax:623-582-6720
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8682363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty