Provider Demographics
NPI:1275727315
Name:FRAKES, AMANDA L (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:FRAKES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:BOX 78534
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8534
Mailing Address - Country:US
Mailing Address - Phone:815-398-9491
Mailing Address - Fax:815-381-7498
Practice Address - Street 1:650 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5944
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085006483363A00000X
IN10001053A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000600746OtherANTHEM
IN300005114Medicaid
IL085006483OtherILLINOIS PHYSICIAN ASSISTANT LICENSE
INP01291690OtherRAILROAD MEDICARE
IN797310MMMMedicare PIN