Provider Demographics
NPI:1225188055
Name:FRAGUA, FRANK FIDEL (LADAC)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:FIDEL
Last Name:FRAGUA
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024
Mailing Address - Country:US
Mailing Address - Phone:505-834-7710
Mailing Address - Fax:
Practice Address - Street 1:110 SHEEP SPRINGS
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024
Practice Address - Country:US
Practice Address - Phone:505-834-3139
Practice Address - Fax:505-834-9507
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3781101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)