Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | ATH.200132 | LA |
Y | 213ES0000X | Sports Medicine | ATH.200132 | LA |
NPI | 1104262617 |
---|---|
Provider Name | Chad Frederickson |
First Address | Baton Rouge, LA 70803-2401 |
Second Address | Baton Rouge, LA 70803-2401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2013 |
Last Update Date | 13/05/2013 |