Provider Demographics
NPI:1982777629
Name:FREDERICKSEN, MARK OWEN (ND)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:OWEN
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2003 SE MAPLE VALLEY HWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:425-652-2430
Mailing Address - Fax:425-291-7899
Practice Address - Street 1:2003 SE MAPLE VALLEY HWY
Practice Address - Street 2:SUITE 212
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057
Practice Address - Country:US
Practice Address - Phone:425-652-2430
Practice Address - Fax:425-291-7899
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA00000737175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath