Provider Demographics
NPI:1417083023
Name:FRAGA, JORGE A (DC)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:FRAGA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5315
Mailing Address - Country:US
Mailing Address - Phone:509-547-4207
Mailing Address - Fax:509-547-4208
Practice Address - Street 1:207 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5315
Practice Address - Country:US
Practice Address - Phone:509-547-4207
Practice Address - Fax:509-547-4208
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002378111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH00002378OtherSTATE LICENSE NUMBER