Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | NE5284 | NE |
NPI | 1003034828 |
---|---|
Provider Name | Tyler Christian Pedersen |
First Address | Omaha, NE 68107-3328 |
Second Address | Omaha, NE 68198-1150 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NE5284 | (02) | NE |