Provider Demographics
NPI:1518027903
Name:FREVERT, ERIC W (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:FREVERT
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 1:1488 18 RD
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-9263
Mailing Address - Country:US
Mailing Address - Phone:719-480-9765
Mailing Address - Fax:
Practice Address - Street 1:1488 18 RD
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-9263
Practice Address - Country:US
Practice Address - Phone:719-480-9765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60921354363A00000X
CO2371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63976587Medicaid