Provider Demographics
NPI:1245564343
Name:FRODERMANN, KATHRYN ELIZABETH JACQUES (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH JACQUES
Last Name:FRODERMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9201 WEST BROADWAY AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7066
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:SUITE 315
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-587-7900
Practice Address - Fax:763-587-7989
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9772363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical