Healthcare Provider Details

I. General information

NPI: 1043740202
Provider Name (Legal Business Name): TAYLOR NICOLE PEDERSEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S ASH ST
BUFFALO MO
65622-8674
US

IV. Provider business mailing address

201 S ASH ST
BUFFALO MO
65622-8674
US

V. Phone/Fax

Practice location:
  • Phone: 417-345-4858
  • Fax: 417-345-6866
Mailing address:
  • Phone: 417-345-4858
  • Fax: 417-345-6866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020009910
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12327A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: