Healthcare Provider Details

I. General information

NPI: 1992317176
Provider Name (Legal Business Name): ASHLYN ARCHER FREDERIKSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 WILSON PARKE AVE STE 150
AUSTIN TX
78726-4061
US

IV. Provider business mailing address

6210 E HWY 290
AUSTIN TX
78723-1098
US

V. Phone/Fax

Practice location:
  • Phone: 737-247-7200
  • Fax: 512-406-7368
Mailing address:
  • Phone: 512-483-9596
  • Fax: 512-406-7621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16175
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA16175
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: