Provider Demographics
NPI:1427358530
Name:FREDERICK, LINDA LOUISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:LOUISE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:675 W NORTH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1665
Mailing Address - Country:US
Mailing Address - Phone:708-538-5900
Mailing Address - Fax:708-538-5910
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:608-334-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004552363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical