Provider Demographics
NPI:1073067401
Name:FREDERICKSEN, NOEL
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:
Last Name:FREDERICKSEN
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 1:55 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1614
Mailing Address - Country:US
Mailing Address - Phone:612-990-4478
Mailing Address - Fax:
Practice Address - Street 1:55 ELM ST
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1614
Practice Address - Country:US
Practice Address - Phone:612-990-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6212111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor