Provider Demographics
NPI:1104160753
Name:FREDERIC, LYDIE-DANIELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LYDIE-DANIELLE
Middle Name:
Last Name:FREDERIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYDIE-DANI
Other - Middle Name:
Other - Last Name:FREDERIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:130 SPEEDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-2315
Mailing Address - Country:US
Mailing Address - Phone:862-242-8053
Mailing Address - Fax:
Practice Address - Street 1:750 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4143
Practice Address - Country:US
Practice Address - Phone:609-394-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016255363A00000X
NJ25MP00345300363A00000X
VA0110010195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant