Provider Demographics
NPI:1548526759
Name:POWERS, FREDERICK EUGENE JR (FNP-BC)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:EUGENE
Last Name:POWERS
Suffix:JR
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-3649
Mailing Address - Country:US
Mailing Address - Phone:406-395-4305
Mailing Address - Fax:406-395-5643
Practice Address - Street 1:286 S LENZNER AVE
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-5685
Practice Address - Country:US
Practice Address - Phone:520-452-0388
Practice Address - Fax:520-452-0388
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4146363LF0000X
MT72263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1548526759Medicaid
MTM011004335Medicare PIN