Provider Demographics
NPI:1750549358
Name:FREDEN, WENDY L (PA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:FREDEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:L
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:5414 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1335
Practice Address - Country:US
Practice Address - Phone:903-581-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-048OtherTRICARE
TX75-1976930-005OtherTRICARE
TX8067NFOtherBCBS
TX8068NFOtherBCBS
TX75-2616977-028OtherTRICARE
TX1750549358OtherNPI
TX201427604Medicaid
TX75-2616977-001OtherTRICARE
TX75-0818167-044OtherTRICARE
TX75-2616977-002OtherTRICARE
TX8070NFOtherBCBS
TX201427603Medicaid
TX201427605Medicaid
TX8069NFOtherBCBS
TX201427606Medicaid
TX75-0818167-015OtherTRICARE
TX75-0818167-022OtherTRICARE
TXP01318066Medicare Oscar/Certification
TX201427603Medicaid
TXTXB160661Medicare PIN
TX75-2616977-002OtherTRICARE
TX201427606Medicaid
TX75-0818167-044OtherTRICARE
TX75-2616977-028OtherTRICARE
TX75-0818167-022OtherTRICARE