Provider Demographics
NPI:1750700118
Name:FREDRICKSON ANESTHESIA STAFFING INC.
Entity type:Organization
Organization Name:FREDRICKSON ANESTHESIA STAFFING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:512-993-4848
Mailing Address - Street 1:15608 INTERLACHEN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-3871
Mailing Address - Country:US
Mailing Address - Phone:512-993-4848
Mailing Address - Fax:
Practice Address - Street 1:2610 S IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5703
Practice Address - Country:US
Practice Address - Phone:512-993-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3665739-01Medicaid
TX3665739-01Medicaid