Provider Demographics
NPI:1659522308
Name:FREDRICKSON, LANCE R (CRNA)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:R
Last Name:FREDRICKSON
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 1:510 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3410
Mailing Address - Country:US
Mailing Address - Phone:903-677-1000
Mailing Address - Fax:903-677-1694
Practice Address - Street 1:510 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3410
Practice Address - Country:US
Practice Address - Phone:903-677-7434
Practice Address - Fax:903-677-1472
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200801739367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3504375-01Medicaid
TX3504375-01Medicaid
TX406324YNR7Medicare PIN