Healthcare Provider Details

I. General information

NPI: 1659568715
Provider Name (Legal Business Name): AMY FRASER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001998
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001998
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: