Healthcare Provider Details

I. General information

NPI: 1477120160
Provider Name (Legal Business Name): ERIC PEDERSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 505-896-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11317
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0053
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: