Basic Information
| Provider Information | |||||||||
| NPI: | 1225091796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PAC MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 ASHTON DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Practice Location | |||||||||
| Address1: | 2716 ASHTON DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1021210 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01047853 | 01 | RR MEDICARE PTAN | OTHER |