Individual
MR. DOUGLAS E FREDERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ARNP
Contact information
Practice address
1947 N FOUNDERS CIR, WICHITA, KS 67206-3548
(316) 613-4640
(316) 689-9769
Mailing address
PO BOX 8035, WICHITA, KS 67208-0035
(316) 689-9135
(316) 689-9667
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
45623
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003719299
MEDICARE
—
05
—
200278930E
—
KS
01
—
20041080A
OK MEDICAID
—
Enumeration date
06/16/2005
Last updated
05/19/2014
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