1831357896 NPI number — LINDSAY S FRETTS PA-C

Table of content: LINDSAY S FRETTS PA-C (NPI 1831357896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831357896 NPI number — LINDSAY S FRETTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRETTS
Provider First Name:
LINDSAY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831357896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1928
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36302-1928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-8087
Provider Business Mailing Address Fax Number:
334-793-8191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 ROSS CLARK CIR BLDG SUITE704
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-712-3738
Provider Business Practice Location Address Fax Number:
334-699-4897
Provider Enumeration Date:
05/27/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA-585 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 585 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA-585 . This is a "AL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 112551700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".