Provider Demographics
NPI:1598876898
Name:FREDRICKSON, WARD
Entity Type:Individual
Prefix:
First Name:WARD
Middle Name:
Last Name:FREDRICKSON
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:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3502 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0761
Practice Address - Country:US
Practice Address - Phone:701-222-2480
Practice Address - Fax:701-222-4537
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5170207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND616OtherBLUE SHIELD
NDCO4118OtherRR MEDICARE
ND17511Medicaid
ND616OtherBLUE SHIELD
NDE59012Medicare UPIN