Healthcare Provider Details

I. General information

NPI: 1053771055
Provider Name (Legal Business Name): CHAD ROGER FEDJE R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 210TH ST
BARRETT MN
56311-1113
US

IV. Provider business mailing address

11911 210TH ST
BARRETT MN
56311-1113
US

V. Phone/Fax

Practice location:
  • Phone: 830-279-4058
  • Fax:
Mailing address:
  • Phone: 830-279-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR-213631-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: