Provider Demographics
NPI:1790127934
Name:NOLLER, FREDRIC E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:FREDRIC
Middle Name:E
Last Name:NOLLER
Suffix:
Gender:M
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 1:107 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3526
Mailing Address - Country:US
Mailing Address - Phone:856-429-1800
Mailing Address - Fax:856-429-1081
Practice Address - Street 1:107 BERLIN RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3526
Practice Address - Country:US
Practice Address - Phone:856-429-1800
Practice Address - Fax:856-429-1081
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00314800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ365793Medicaid
NJ314344CJAMedicare PIN