Individual
FREDERIC W NORTHERN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
707 PASEO DE PERALTA, SANTA FE, NM 87501-1922
(505) 989-8707
Mailing address
401 E SENECA AVE, MCALESTER, OK 74501-6427
(918) 916-6894
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA2013-0085
NM
363AM0700X
Medical Physician Assistant
Primary
PA2013-0085
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
N0018092
—
NM
Enumeration date
01/06/2014
Last updated
07/30/2025
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