Provider Demographics
NPI:1497877344
Name:FREDEKING, TOBIAS
Entity Type:Individual
Prefix:
First Name:TOBIAS
Middle Name:
Last Name:FREDEKING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 PINE ISLAND CIR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7880
Mailing Address - Country:US
Mailing Address - Phone:209-605-6356
Mailing Address - Fax:
Practice Address - Street 1:2009 PINE ISLAND CIR
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-7880
Practice Address - Country:US
Practice Address - Phone:209-605-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily