MEDICARE: MS. PENELOPE FRESEMAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9101742	FL

General Provider Information

NPI Number	:	1366426124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PENELOPE FRESEMAN PA-C

Provider Business Mailing Address
First Line	:	2430 SW FALCON CIR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2922
Country	:	US
Telephone Number	:	772-873-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 SE HILLMOOR DR
Second Line	:	SUITE 5
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-7552
Country	:	US
Telephone Number	:	772-335-0060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	07/08/2007

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