Basic Information
| Provider Information | |||||||||
| NPI: | 1275520165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2540 E SHARON ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727036599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792511905 | ||||||||
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| Practice Location | |||||||||
| Address1: | RR 6 BOX 840 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749608703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | 9186963879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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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 | 363AM0700X | PA1384 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA02983 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA216 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1601384 | 05 | OK | MEDICAID |