Provider Demographics
NPI:1619204690
Name:FREDERICK, ROBERT RAY (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3366 NW EXPRESSWAY STE 730
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4454
Mailing Address - Country:US
Mailing Address - Phone:405-945-4905
Mailing Address - Fax:405-945-4906
Practice Address - Street 1:3366 NW EXPRESSWAY STE 730
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4454
Practice Address - Country:US
Practice Address - Phone:405-945-4905
Practice Address - Fax:405-945-4906
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA457363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical