Healthcare Provider Details

I. General information

NPI: 1043620461
Provider Name (Legal Business Name): FRED JAY FRAZIER III APRN,PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOSPITAL PLZ
CLARKSBURG WV
26301-9316
US

IV. Provider business mailing address

224 THOMPSON DAIRY RD
FARMINGTON WV
26571-9000
US

V. Phone/Fax

Practice location:
  • Phone: 304-969-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN79419-PMHNP-BC
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: