Healthcare Provider Details

I. General information

NPI: 1407342181
Provider Name (Legal Business Name): MR. NICHOLAS FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 EDGE OF WOODS RD
SAINT AUGUSTINE FL
32092-3720
US

IV. Provider business mailing address

325 EDGE OF WOODS RD
SAINT AUGUSTINE FL
32092-3720
US

V. Phone/Fax

Practice location:
  • Phone: 904-859-4033
  • Fax:
Mailing address:
  • Phone: 904-859-4033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: