Healthcare Provider Details

I. General information

NPI: 1952427734
Provider Name (Legal Business Name): REGINA D PEDERSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 CAUGHLIN XING STE 100
RENO NV
89519-0692
US

IV. Provider business mailing address

4790 CAUGHLIN PKWY STE 379
RENO NV
89519-0907
US

V. Phone/Fax

Practice location:
  • Phone: 775-323-7828
  • Fax: 775-348-5809
Mailing address:
  • Phone: 775-323-7828
  • Fax: 775-348-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA463
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: