Basic Information
| Provider Information | |||||||||
| NPI: | 1518057314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERIKSEN | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | E | ||||||||
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| OtherLastName: | FREDERIKSEN | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 10085 DOUBLE R BLVD STE 325 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895214832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825073 | ||||||||
| FaxNumber: | 7759823958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 16719 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 16719 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RB0002X | 16719 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 963137 | 05 | AZ | MEDICAID | 201313100 | 05 | IN | MEDICAID | P01588213 | 01 | IN | RR MEDICARE | OTHER |