Provider Demographics
NPI:1437745650
Name:FRAER, COREY S (PTA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:S
Last Name:FRAER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 IRON HORSE LN APT 127
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-2159
Mailing Address - Country:US
Mailing Address - Phone:443-617-1922
Mailing Address - Fax:
Practice Address - Street 1:9050 IRON HORSE LN APT 127
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-2159
Practice Address - Country:US
Practice Address - Phone:443-617-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5186225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty