Provider Demographics
NPI:1154309011
Name:FRASER, LESLEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:A
Last Name:FRASER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5114
Mailing Address - Country:US
Mailing Address - Phone:970-350-2426
Mailing Address - Fax:970-350-2452
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5114
Practice Address - Country:US
Practice Address - Phone:970-350-2426
Practice Address - Fax:970-350-2452
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01366335Medicaid
COP00944733OtherMEDICARE RAILROAD CARRIER PTAN
COC21158Medicare PIN
COCOA102094Medicare PIN
COP00944733OtherMEDICARE RAILROAD CARRIER PTAN