Provider Demographics
NPI:1811198690
Name:FREDERICK, WENDY A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:A
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:831 AMELIA CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3373
Mailing Address - Country:US
Mailing Address - Phone:847-223-2218
Mailing Address - Fax:
Practice Address - Street 1:904 S MILWAUKEE AVE STE B
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3215
Practice Address - Country:US
Practice Address - Phone:847-990-7220
Practice Address - Fax:847-984-2597
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant