Provider Demographics
NPI:1073551263
Name:FRAIZER, JAISON C (PA-C)
Entity Type:Individual
Prefix:
First Name:JAISON
Middle Name:C
Last Name:FRAIZER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1810
Mailing Address - Country:US
Mailing Address - Phone:909-593-7437
Mailing Address - Fax:909-593-0318
Practice Address - Street 1:2776 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1810
Practice Address - Country:US
Practice Address - Phone:909-593-7437
Practice Address - Fax:909-593-0318
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ55533Medicare UPIN