Provider Demographics
NPI:1164892972
Name:MCWANE, FREDERICK IV (ATC/L)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:MCWANE
Suffix:IV
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4800
Mailing Address - Country:US
Mailing Address - Phone:952-977-0467
Mailing Address - Fax:952-806-5469
Practice Address - Street 1:8100 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55431-4800
Practice Address - Country:US
Practice Address - Phone:952-977-0467
Practice Address - Fax:952-806-5469
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer