Provider Demographics
NPI:1528472230
Name:PEDERSEN, SARAH (PT)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0717
Mailing Address - Country:US
Mailing Address - Phone:208-342-7088
Mailing Address - Fax:
Practice Address - Street 1:3277 E LOUISE DR
Practice Address - Street 2:SUITE 410
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9359
Practice Address - Country:US
Practice Address - Phone:208-489-5800
Practice Address - Fax:208-489-4065
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist