Provider Demographics
NPI:1306918990
Name:FEDOROWICZ, FREDERICK T (PA-C)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:T
Last Name:FEDOROWICZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 W NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2740
Mailing Address - Country:US
Mailing Address - Phone:734-243-4344
Mailing Address - Fax:
Practice Address - Street 1:600 E LAFAYETTE BLVD
Practice Address - Street 2:J426
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2927
Practice Address - Country:US
Practice Address - Phone:313-225-8173
Practice Address - Fax:313-225-0956
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant