Provider Demographics
NPI:1417469685
Name:FRASER, PAMELA JEANETTE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEANETTE
Last Name:FRASER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:TX
Mailing Address - Zip Code:78621-1208
Mailing Address - Country:US
Mailing Address - Phone:406-599-9190
Mailing Address - Fax:
Practice Address - Street 1:14028 N HWY 183 STE D120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-5992
Practice Address - Country:US
Practice Address - Phone:512-250-8800
Practice Address - Fax:512-250-8800
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT119246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty