Provider Demographics
NPI:1346215894
Name:FREDERICKSON, RACHEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:L
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:L
Other - Last Name:CHAPPELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9348 GRAND CORDERA PKWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-7023
Mailing Address - Country:US
Mailing Address - Phone:719-355-1585
Mailing Address - Fax:719-623-2983
Practice Address - Street 1:9348 GRAND CORDERA PKWY
Practice Address - Street 2:160
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-7023
Practice Address - Country:US
Practice Address - Phone:719-355-1585
Practice Address - Fax:719-623-2983
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3263363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL95071Medicare ID - Type Unspecified
ILP75112Medicare UPIN