Healthcare Provider Details

I. General information

NPI: 1760163661
Provider Name (Legal Business Name): HAILEY ANN FREDRIKSSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13460 N 94TH DR STE J1
PEORIA AZ
85381-4264
US

IV. Provider business mailing address

13460 N 94TH DR STE J1
PEORIA AZ
85381-4264
US

V. Phone/Fax

Practice location:
  • Phone: 238-768-8166
  • Fax: 623-298-0168
Mailing address:
  • Phone: 238-768-8166
  • Fax: 623-298-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: