Provider Demographics
NPI:1912328410
Name:NATIVIDAD, FREDERICK MAURICE BALDERRAMA
Entity Type:Individual
Prefix:
First Name:FREDERICK MAURICE
Middle Name:BALDERRAMA
Last Name:NATIVIDAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 E 7000 S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6877
Mailing Address - Country:US
Mailing Address - Phone:801-495-5307
Mailing Address - Fax:
Practice Address - Street 1:1952 E 7000 S
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6877
Practice Address - Country:US
Practice Address - Phone:801-495-5307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist