Provider Demographics
NPI:1467514935
Name:CARDINAL, FREDERICK MARVIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:MARVIN
Last Name:CARDINAL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:CA
Mailing Address - Zip Code:95713-9760
Mailing Address - Country:US
Mailing Address - Phone:530-637-4671
Mailing Address - Fax:530-637-4581
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-688-2574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA1556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3525610Medicaid
CARN3525610Medicaid