MEDICARE: JESSICA DANIELLE FRASER PHYSICIAN ASSISTANT

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	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1437591625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DANIELLE FRASER PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	985 MANOR LN
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-7516
Country	:	US
Telephone Number	:	631-943-7516
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 BRENTWOOD RD STE 101
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8031
Country	:	US
Telephone Number	:	631-589-7400
Fax Number	:

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

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	10/16/2019

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