=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043620461
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRED JAY FRAZIER III APRN,PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2014
-----------------------------------------------------
Last Update Date | 05/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 HOSPITAL PLZ
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301-9316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-969-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 THOMPSON DAIRY RD
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26571-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN79419-PMHNP-BC
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------