Healthcare Provider Details

I. General information

NPI: 1134869696
Provider Name (Legal Business Name): KYLE MATTHEW FREDRICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18484 KACHINA CT
LAKEVILLE MN
55044-4886
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025-02382
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82141
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: