Healthcare Provider Details

I. General information

NPI: 1316474240
Provider Name (Legal Business Name): FREDERICK WADE LINCOLN JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 GRANITE RUN DRIVE
LANCASTER PA
17601-6823
US

IV. Provider business mailing address

231 GRANITE RUN DRIVE
LANCASTER PA
17601-6823
US

V. Phone/Fax

Practice location:
  • Phone: 717-560-4200
  • Fax: 717-560-4159
Mailing address:
  • Phone: 717-560-4200
  • Fax: 717-560-4159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN612723
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: