Provider Demographics
NPI:1285601740
Name:FREDERICK, BARRY L (PA-C, MPAS, RN, BSN)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PA-C, MPAS, RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 GAUSE BLVD # 75
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 ROBERT BLVD STE 240
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2005
Practice Address - Country:US
Practice Address - Phone:985-646-3662
Practice Address - Fax:985-646-3691
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10586363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant