Provider Demographics
NPI:1689071805
Name:FREEMAN, KRISTINE REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:REBECCA
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:REBECCA
Other - Last Name:GAUTHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:703-940-8692
Practice Address - Street 1:8503 ARLINGTON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-280-5390
Practice Address - Fax:703-280-9596
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110006625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689071805Medicaid