Basic Information
| Provider Information | |||||||||
| NPI: | 1801375340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | A | ||||||||
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| OtherLastName: | FREEMAN | ||||||||
| OtherFirstName: | MISCHA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3226 NICOL AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946023118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274177155 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2919 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152290500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.