1750549358 NPI number — WENDY L FREDEN PA

Table of content: WENDY L FREDEN PA (NPI 1750549358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750549358 NPI number — WENDY L FREDEN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDEN
Provider First Name:
WENDY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LITTLE
Provider Other First Name:
WENDY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750549358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841656
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-531-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5414 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-581-1601
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2008

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: 363A00000X , with the licence number:  PA02370 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 75-0818167-048 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-1976930-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8067NF . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8068NF . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-028 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1750549358 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 201427604 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-2616977-001 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-0818167-044 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-002 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8070NF . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 201427603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201427605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8069NF . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 201427606 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-0818167-015 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-0818167-022 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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