Provider Demographics
NPI:1730131178
Name:FRIEL, FREDDIE (PA)
Entity Type:Individual
Prefix:
First Name:FREDDIE
Middle Name:
Last Name:FRIEL
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 1:301 W MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7656
Mailing Address - Country:US
Mailing Address - Phone:208-342-8200
Mailing Address - Fax:208-342-8202
Practice Address - Street 1:301 W MYRTLE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7656
Practice Address - Country:US
Practice Address - Phone:208-342-8200
Practice Address - Fax:208-342-8202
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804251900Medicaid
ID804251900Medicaid
ID16654201Medicare PIN