Basic Information
| Provider Information | |||||||||
| NPI: | 1548526759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWERS | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 521 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HAVRE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 595013649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063954305 | ||||||||
| FaxNumber: | 4063955643 | ||||||||
| Practice Location | |||||||||
| Address1: | 286 S LENZNER AVE | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856355685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204520388 | ||||||||
| FaxNumber: | 5204520388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2012 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP4146 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 72263 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1548526759 | 05 | MT | MEDICAID |