Provider Demographics
NPI:1962057034
Name:FREDRICKS, RYAN TIMOTHY (CRNA)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:TIMOTHY
Last Name:FREDRICKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9170 JACARANDA WAY
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-7417
Mailing Address - Country:US
Mailing Address - Phone:408-607-0263
Mailing Address - Fax:
Practice Address - Street 1:9170 JACARANDA WAY
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-7417
Practice Address - Country:US
Practice Address - Phone:408-607-0263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95135050163W00000X
CA95001662367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse