Provider Demographics
NPI:1184684540
Name:FREITAG, BRANDT D (PA)
Entity type:Individual
Prefix:
First Name:BRANDT
Middle Name:D
Last Name:FREITAG
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:13025 8TH ST
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758-7634
Practice Address - Country:US
Practice Address - Phone:715-597-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42968800Medicaid
WI42968800Medicaid
WI0233 20195Medicare ID - Type Unspecified