Provider Demographics
NPI:1043393978
Name:FRESHWATER, GREGORY A (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:FRESHWATER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 WELLINGTON AVE
Mailing Address - Street 2:PO BOX 62
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6123
Mailing Address - Country:US
Mailing Address - Phone:970-298-7106
Mailing Address - Fax:970-298-7177
Practice Address - Street 1:710 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6123
Practice Address - Country:US
Practice Address - Phone:970-298-7106
Practice Address - Fax:970-298-7177
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02589737Medicaid
COR63911Medicare UPIN
CO805345Medicare ID - Type Unspecified
CO02589737Medicaid