Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | DO2536 | ME |
Y | 207Q00000X | Family Doctor | O-1330 | ID |
NPI | 1003170176 |
---|---|
Provider Name | Christina Marie Freston |
First Address | Meridian, ID 83642-2193 |
Second Address | Meridian, ID 83642-2193 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2012 |
Last Update Date | 09/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E400232990 | MEDICARE PTAN (01) | ME |