Provider Demographics
NPI:1962090621
Name:FREITAG, MARY LOU
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:FREITAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:
Practice Address - Street 1:324 4TH ST
Practice Address - Street 2:
Practice Address - City:MYRTLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97458-1074
Practice Address - Country:US
Practice Address - Phone:541-572-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202010537NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500789478Medicaid