The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000-2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p<0.0001) lacking traffic control devices (p<0.0001) and artificial lighting (p<0.0001). Alcohol was a significant cofactor in both environments (40% urban vs. 55% rural; p=0.0239). Prevention of AI/AN deaths should include engineering countermeasures specific to the needs of rural (lighting) and urban (medians with barriers) environments and address drinking behavior in both populations.