Healthcare Provider Details

I. General information

NPI: 1265094965
Provider Name (Legal Business Name): CHRISTOPHER RAYMOND FREDERICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LEAD AVE SE
ALBUQUERQUE NM
87106-5215
US

IV. Provider business mailing address

408 VASSAR DR SE
ALBUQUERQUE NM
87106-2806
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-7000
  • Fax:
Mailing address:
  • Phone: 505-629-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56664
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number56664
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: