Healthcare Provider Details

I. General information

NPI: 1669781381
Provider Name (Legal Business Name): ERIN MARIE PEDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERIN MARIE JUNGELS

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

V. Phone/Fax

Practice location:
  • Phone: 320-529-4687
  • Fax:
Mailing address:
  • Phone: 320-202-8949
  • Fax: 320-202-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1491
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: