Provider Demographics
NPI:1689735482
Name:FEDORICK, KARIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KARIE
Middle Name:LYNN
Last Name:FEDORICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 E CHANDLER BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7645
Mailing Address - Country:US
Mailing Address - Phone:480-961-5956
Mailing Address - Fax:
Practice Address - Street 1:2915 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2427
Practice Address - Country:US
Practice Address - Phone:480-776-0626
Practice Address - Fax:480-776-0627
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2779363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108426Medicare PIN
AZQ64912Medicare UPIN