Provider Demographics
NPI:1275924755
Name:FRIESEMA, KIMBERLY ANNE (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:FRIESEMA
Suffix:
Gender:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5043
Mailing Address - Fax:704-384-8895
Practice Address - Street 1:125 QUEENS RD STE 330
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3419
Practice Address - Country:US
Practice Address - Phone:704-384-5043
Practice Address - Fax:704-384-8895
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05581363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2181PAMedicaid
NC1275924755Medicaid
SC2181PAMedicaid
NCNCN015EMedicare PIN
NCNCN015AMedicare PIN
NCNCN015CMedicare PIN
NC1275924755Medicaid
NCNCN015BMedicare PIN