Provider Demographics
NPI:1750997300
Name:FREEMAN, ANTWON TARIK
Entity type:Individual
Prefix:
First Name:ANTWON
Middle Name:TARIK
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 SUMMERTIME DR APT 2609
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5626
Mailing Address - Country:US
Mailing Address - Phone:170-461-5265
Mailing Address - Fax:
Practice Address - Street 1:2129 SUMMERTIME DR APT 2609
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5626
Practice Address - Country:US
Practice Address - Phone:704-615-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC85-1686925Medicaid