Provider Demographics
NPI:1366426124
Name:FRESEMAN, PENELOPE (PA-C)
Entity type:Individual
Prefix:MS
First Name:PENELOPE
Middle Name:
Last Name:FRESEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 SW FALCON CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2922
Mailing Address - Country:US
Mailing Address - Phone:772-873-8800
Mailing Address - Fax:
Practice Address - Street 1:1701 SE HILLMOOR DR
Practice Address - Street 2:SUITE 5
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-335-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101742363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical