Provider Demographics
NPI:1780020495
Name:FRESENBURG, NATASHA BROOKE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:BROOKE
Last Name:FRESENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:NATASHA
Other - Middle Name:B
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20 PROGRESS POINT PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-2207
Mailing Address - Country:US
Mailing Address - Phone:636-344-2400
Mailing Address - Fax:
Practice Address - Street 1:20 PROGRESS POINT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2207
Practice Address - Country:US
Practice Address - Phone:636-344-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015008258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant