Provider Demographics
NPI:1306234604
Name:FREDERICK, MARK (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1140
Mailing Address - Country:US
Mailing Address - Phone:913-294-4308
Mailing Address - Fax:
Practice Address - Street 1:908 N PEARL ST
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1140
Practice Address - Country:US
Practice Address - Phone:913-294-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist