Provider Demographics
NPI:1144794629
Name:FREEBERG, SCOTT KRISTOFER (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:KRISTOFER
Last Name:FREEBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 MADRONE LN
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7844
Mailing Address - Country:US
Mailing Address - Phone:805-748-3897
Mailing Address - Fax:
Practice Address - Street 1:1515 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7092
Practice Address - Country:US
Practice Address - Phone:805-737-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant