Provider Demographics
NPI:1659522308
Name:FREDRICKSON, LANCE R (CRNA)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:R
Last Name:FREDRICKSON
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:509-764-3244
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120956367500000X
WAAP61610317367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2307808Medicaid
TX3504375-01Medicaid
TX406324YNR7Medicare PIN