Healthcare Provider Details

I. General information

NPI: 1013441930
Provider Name (Legal Business Name): FREESTATE HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4723 E DOUGLAS AVE
WICHITA KS
67218-1012
US

IV. Provider business mailing address

4723 E DOUGLAS AVE
WICHITA KS
67218-1012
US

V. Phone/Fax

Practice location:
  • Phone: 888-505-1776
  • Fax: 888-505-1776
Mailing address:
  • Phone: 888-505-1776
  • Fax: 888-505-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number04-33447
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-33447
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-33447
License Number StateKS

VIII. Authorized Official

Name: ELISHA YAGHMAI
Title or Position: PRESIDENT
Credential: MD, MPH&TM
Phone: 888-505-1776