Provider Demographics
NPI:1306142047
Name:FREESE, MEGAN ANGELA (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ANGELA
Last Name:FREESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ANGELA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1125
Mailing Address - Fax:704-316-1143
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:STE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-316-1125
Practice Address - Fax:704-316-1143
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE0010-02747363A00000X
NC0010-02747363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101453Medicaid
NC2762631Medicare PIN