Provider Demographics
NPI:1265094965
Name:FREDERICKS, CHRISTOPHER RAYMOND
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RAYMOND
Last Name:FREDERICKS
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 1:408 VASSAR DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2806
Mailing Address - Country:US
Mailing Address - Phone:505-629-2079
Mailing Address - Fax:
Practice Address - Street 1:1100 LEAD AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5215
Practice Address - Country:US
Practice Address - Phone:505-224-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM56664363LF0000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily