Provider Demographics
NPI:1255678280
Name:CREEKMORE, FREDDY JR (PA-C)
Entity Type:Individual
Prefix:
First Name:FREDDY
Middle Name:
Last Name:CREEKMORE
Suffix:JR
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 1:1600 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-7630
Mailing Address - Country:US
Mailing Address - Phone:336-646-7272
Mailing Address - Fax:
Practice Address - Street 1:1600 RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-7630
Practice Address - Country:US
Practice Address - Phone:336-646-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY99871835P1200X
TN317591835P1200X
UT15237317011835P1200X
VA0110006193363A00000X
NC0010-08618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy