Provider Demographics
NPI:1417153982
Name:FRAZINE, CARLA D (PA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:D
Last Name:FRAZINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:D
Other - Last Name:MITTENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-366-7650
Mailing Address - Fax:270-443-7080
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-366-7650
Practice Address - Fax:270-443-7080
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY710006710Medicaid
KY710006710Medicaid