Provider Demographics
NPI:1154640225
Name:FREDERICKSON, NICHOLAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:W
Last Name:FREDERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PATIENTS FIRST DRIVE SUITE 3300
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090
Mailing Address - Country:US
Mailing Address - Phone:636-239-7344
Mailing Address - Fax:636-239-9436
Practice Address - Street 1:901 PATIENTS FIRST DRIVE SUITE 3300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090
Practice Address - Country:US
Practice Address - Phone:636-239-7344
Practice Address - Fax:636-239-9436
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8906207R00000X
MO2016012330207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine