Provider Demographics
NPI:1538959523
Name:PEDERSEN, KALEN (PTA)
Entity type:Individual
Prefix:
First Name:KALEN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:813 LOWER MILL BAY RD
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-7314
Mailing Address - Country:US
Mailing Address - Phone:907-486-4499
Mailing Address - Fax:907-486-8211
Practice Address - Street 1:813 LOWER MILL BAY RD
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7314
Practice Address - Country:US
Practice Address - Phone:907-486-4499
Practice Address - Fax:907-486-8211
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK124594225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant