Basic Information
| Provider Information | |||||||||
| NPI: | 1962090621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREITAG | ||||||||
| FirstName: | MARY LOU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MYRTLE POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974581074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415722111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2021 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 202010537NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500789478 | 05 | OR | MEDICAID |