Provider Demographics
NPI:1558385401
Name:FREESE, KRISTINA KATHRYN (PA)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:KATHRYN
Last Name:FREESE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400 - CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-438-7373
Mailing Address - Fax:313-438-7375
Practice Address - Street 1:2799 W GRAND BLVD # K-11
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-433-7893
Practice Address - Fax:313-916-7610
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-04-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32070023Medicare PIN