Provider Demographics
NPI:1114178654
Name:FREESTONE, DEREK JOSEPH (PAC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JOSEPH
Last Name:FREESTONE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 BOILING SPRINGS RD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4201
Mailing Address - Country:US
Mailing Address - Phone:864-582-6396
Mailing Address - Fax:864-542-2939
Practice Address - Street 1:1330 BOILING SPRINGS RD
Practice Address - Street 2:SUITE 1600
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4201
Practice Address - Country:US
Practice Address - Phone:864-582-6396
Practice Address - Fax:864-542-2939
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1358363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA3424Medicare UPIN
SCAA34241223Medicare PIN