Provider Demographics
NPI:1518294495
Name:FREEBORN, KACIE ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:KACIE
Middle Name:ANN
Last Name:FREEBORN
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:4045 WEST ROYAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-0900
Mailing Address - Fax:231-935-0308
Practice Address - Street 1:4045 WEST ROYAL DRIVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0900
Practice Address - Fax:231-935-0308
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005684363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical