Provider Demographics
NPI:1093743957
Name:FREDERICK, JEFFREY ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4200 W MEMORIAL RD
Mailing Address - Street 2:606
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9350
Mailing Address - Country:US
Mailing Address - Phone:405-755-1930
Mailing Address - Fax:405-755-2795
Practice Address - Street 1:3650 W ROCK CREEK RD
Practice Address - Street 2:110A
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2202
Practice Address - Country:US
Practice Address - Phone:405-364-2666
Practice Address - Fax:405-364-9627
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OKPA 936363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100189640 AMedicaid
OK100189640 AMedicaid