Provider Demographics
NPI:1861211062
Name:FREDERICK, RONALD S
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:S
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SHORELINE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-4589
Mailing Address - Country:US
Mailing Address - Phone:718-207-2078
Mailing Address - Fax:
Practice Address - Street 1:146 SHORELINE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-4589
Practice Address - Country:US
Practice Address - Phone:718-207-2078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95040523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily