Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | R41352 | ND |
N | 363LG0600X | Nurse Practitioner - Gerontology | R41352 | ND |
NPI | 1013319334 |
---|---|
Provider Name | Mr. Nicholas Henry Frederiksen |
First Address | Fargo, ND 58108-6001 |
Second Address | Fargo, ND 58103-6132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2014 |
Last Update Date | 28/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1463647 | (05) | ND |