1245564343 NPI number — KATHRYN ELIZABETH JACQUES FRODERMANN PA-C

Table of content: KATHRYN ELIZABETH JACQUES FRODERMANN PA-C (NPI 1245564343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245564343 NPI number — KATHRYN ELIZABETH JACQUES FRODERMANN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRODERMANN
Provider First Name:
KATHRYN
Provider Middle Name:
ELIZABETH JACQUES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACQUES
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245564343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9201 WEST BROADWAY AVE
Provider Second Line Business Mailing Address:
SUITE 601
Provider Business Mailing Address City Name:
BROOKLYN PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-587-7900
Provider Business Mailing Address Fax Number:
763-587-7066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3366 OAKDALE AVE N
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
ROBBINSDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-587-7900
Provider Business Practice Location Address Fax Number:
763-587-7989
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  9772 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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