Provider Demographics
NPI:1174677504
Name:FRAYKOR, MICHAEL JR (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FRAYKOR
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19465 DEERFIELD AVENUE, SUITE 401
Practice Address - Street 2:STE 403
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1707
Practice Address - Country:US
Practice Address - Phone:703-723-5700
Practice Address - Fax:703-723-5778
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06319OtherMEDICARE GROUP PIN
VA30015827950001Medicaid
VA1174677504Medicaid