Provider Demographics
NPI:1104812981
Name:FREEMAN, BRAIDON FORREST (PA C)
Entity type:Individual
Prefix:
First Name:BRAIDON
Middle Name:FORREST
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-624-9112
Mailing Address - Fax:
Practice Address - Street 1:105 W 8TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2318
Practice Address - Country:US
Practice Address - Phone:509-624-9112
Practice Address - Fax:503-297-8148
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA 01014363A00000X
WAPA61281463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604585Medicaid
ORR130926Medicare PIN
OR178088Medicare PIN
Q39352Medicare UPIN