Provider Demographics
NPI:1225091796
Name:FREE, STEPHEN JOHN (PAC MPAS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:FREE
Suffix:
Gender:M
Credentials:PAC MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2489
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:910-251-0421
Practice Address - Street 1:2716 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:910-251-0421
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1021210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01047853OtherRR MEDICARE PTAN
S68058Medicare UPIN
NC5064AMedicare PIN