Provider Demographics
NPI:1730637794
Name:POWELL, FRED M (CRNP)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:POWELL
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:100 WILSON RD
Practice Address - Street 2:
Practice Address - City:BENTLEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:15314-1028
Practice Address - Country:US
Practice Address - Phone:724-239-2390
Practice Address - Fax:724-239-2393
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP016579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA014582OtherCAMP HILL MEDICARE
PA391827OtherFQHC
PA391812OtherFQHC
PA1007288440030Medicaid
PA1007288440027Medicaid
PA1007288440104Medicaid
PA391809OtherFQHC
PA1007288440105Medicaid
PA391902OtherFQHC