Healthcare Provider Details

I. General information

NPI: 1982905683
Provider Name (Legal Business Name): IDA LEE FRASER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 W PIERCE ST SUITE 4A
CARLSBAD NM
88220-3537
US

IV. Provider business mailing address

2402 W PIERCE ST SUITE A
CARLSBAD NM
88220-3537
US

V. Phone/Fax

Practice location:
  • Phone: 575-234-9964
  • Fax: 575-234-3438
Mailing address:
  • Phone: 575-234-9964
  • Fax: 575-234-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP 01698
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: