Provider Demographics
NPI:1679152664
Name:FREDENBURG, GLENN H
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:H
Last Name:FREDENBURG
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 1:9467 STATE ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12921-2043
Mailing Address - Country:US
Mailing Address - Phone:518-335-5097
Mailing Address - Fax:
Practice Address - Street 1:40 LA RIVIERE DR STE 201
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4344
Practice Address - Country:US
Practice Address - Phone:518-335-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily