Basic Information
| Provider Information | |||||||||
| NPI: | 1205195088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTLEDER | ||||||||
| FirstName: | FREDRICK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4465 S 900 E | ||||||||
| Address2: | STE 275 | ||||||||
| City: | MILLCREEK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841242644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Practice Location | |||||||||
| Address1: | 5803 NEAL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550822177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.