MEDICARE: LARS PEDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1760973705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARS PEDERSON

Provider Business Mailing Address
First Line	:	7308 NW 114TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-2703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7308 NW 114TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162
Country	:	US
Telephone Number	:	405-473-5817
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2018
Last Update Date	:	12/13/2018

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Directions to “ LARS PEDERSON ” Practice Location

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