Provider Demographics
NPI:1730639451
Name:FREGOSO, KRISTEN ABBI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ABBI
Last Name:FREGOSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:ABBI
Other - Last Name:CHAFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3001 GREEN BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064
Mailing Address - Country:US
Mailing Address - Phone:847-688-6755
Mailing Address - Fax:847-688-2751
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:814-713-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IL085006060363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical