Provider Demographics
NPI:1164870630
Name:FREDERICK, RYAN (RN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NEW KARNER RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-3840
Mailing Address - Country:US
Mailing Address - Phone:518-431-1650
Mailing Address - Fax:
Practice Address - Street 1:401 NEW KARNER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-3840
Practice Address - Country:US
Practice Address - Phone:518-431-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709127-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse