Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1326622739 |
---|---|
Provider Name | Vanessa Pederson |
First Address | Tulsa, OK 74146-5218 |
Second Address | Tulsa, OK 74146-5218 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2021 |
Last Update Date | 11/05/2021 |