Basic Information
| Provider Information | |||||||||
| NPI: | 1366418840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIDIRICI | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
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| Credential: | AA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORAS | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | F | ||||||||
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| OtherCredential: | AA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3929 MOUNTAIN TRAIL LOOP NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871447000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083329398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 31 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 6 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.