Provider Demographics
NPI:1548682842
Name:NORTHERN, FREDERIC W (PA-C)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:W
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-6427
Mailing Address - Country:US
Mailing Address - Phone:918-916-6894
Mailing Address - Fax:
Practice Address - Street 1:707 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1922
Practice Address - Country:US
Practice Address - Phone:505-989-8707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0085363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical