Provider Demographics
NPI:1881943363
Name:FREITAS, JEREMY M (PA)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:M
Last Name:FREITAS
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 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:870 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2192
Practice Address - Country:US
Practice Address - Phone:704-867-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2127363A00000X
NC0010-07207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730010OtherNSC #