Healthcare Provider Details

I. General information

NPI: 1699045823
Provider Name (Legal Business Name): AMBER NIKOLE FREEMAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 PARKWAY DR
FORT OGLETHORPE GA
30742-4248
US

IV. Provider business mailing address

645 ANTELOPE BLVD STE 24
RED BLUFF CA
96080-2463
US

V. Phone/Fax

Practice location:
  • Phone: 67-956-2846
  • Fax: 706-956-2850
Mailing address:
  • Phone: 530-528-7650
  • Fax: 530-528-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9963
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: