Provider Demographics
NPI:1477248870
Name:FRAZIER, JUSTIN MATTHEW
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 34TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4023
Mailing Address - Country:US
Mailing Address - Phone:612-559-6488
Mailing Address - Fax:
Practice Address - Street 1:415 34TH ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4023
Practice Address - Country:US
Practice Address - Phone:612-559-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDT.0000614390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program