Provider Demographics
NPI:1174528053
Name:FREDERICK, DOUGLAS E (ARNP)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:E
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:1947 N FOUNDERS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3548
Practice Address - Country:US
Practice Address - Phone:316-613-4640
Practice Address - Fax:316-689-9769
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45623363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
20041080AOtherOK MEDICAID
KS200278930EMedicaid
003719299OtherMEDICARE
20041080AOtherOK MEDICAID
KS161359Medicare ID - Type Unspecified
KS200278930AMedicaid