Healthcare Provider Details

I. General information

NPI: 1033885504
Provider Name (Legal Business Name): SAMANTHA ELLEN PEDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA E BOARDMAN

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 S 56TH ST STE 2
LINCOLN NE
68516-1891
US

IV. Provider business mailing address

5200 S 56TH ST STE 2
LINCOLN NE
68516-1891
US

V. Phone/Fax

Practice location:
  • Phone: 402-421-6200
  • Fax: 402-421-6070
Mailing address:
  • Phone: 402-421-6200
  • Fax: 402-421-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2565
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2565
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: