MEDICARE: MR. JOHN PHILLIP FRASURE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1049273
2	363A00000X	Physician Assistant	PA05105	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA05105	OTHER	TX	STATE LICENSE

General Provider Information

NPI Number	:	1093787400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN PHILLIP FRASURE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 HALEY RD
Second Line	:
City	:	JOHNSON CITY
State	:	TX
Zip	:	78636-4617
Country	:	US
Telephone Number	:	830-868-4033
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	12/08/2021

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