Provider Demographics
NPI:1396040770
Name:FREUDENBERG, ELISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:FREUDENBERG
Suffix:
Gender:F
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:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1921 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-3606
Practice Address - Country:US
Practice Address - Phone:360-538-0135
Practice Address - Fax:360-533-3475
Is Sole Proprietor?:No
Enumeration Date:2011-01-17
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60328816363A00000X
ORPA160675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant