Healthcare Provider Details

I. General information

NPI: 1760648117
Provider Name (Legal Business Name): MIKHAIL WENUTU FRASER-GRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

869 N CHERRY ST
TULARE CA
93274-2207
US

IV. Provider business mailing address

111 N SEPULVEDA BLVD SUITE 210
MANHATTAN BEACH CA
90266-6861
US

V. Phone/Fax

Practice location:
  • Phone: 559-688-0821
  • Fax: 818-587-2493
Mailing address:
  • Phone: 310-379-2134
  • Fax: 310-379-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: