Healthcare Provider Details

I. General information

NPI: 1013319334
Provider Name (Legal Business Name): NICHOLAS HENRY FREDERIKSEN APRN,CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax: 701-364-8078
Mailing address:
  • Phone: 701-364-8000
  • Fax: 701-364-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR41352
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR41352
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: