Provider Demographics
NPI:1396053617
Name:TIENCKEN, FREDERICK R (RPA-C)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:R
Last Name:TIENCKEN
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E. RIDGEWOOD AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-327-8600
Mailing Address - Fax:201-327-8225
Practice Address - Street 1:1200 E. RIDGEWOOD AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-327-8600
Practice Address - Fax:201-327-8225
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014271363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical