Provider Demographics
NPI:1487660585
Name:FRALEY, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:FRALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W I 35 FRONTAGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7399
Mailing Address - Country:US
Mailing Address - Phone:405-471-5460
Mailing Address - Fax:405-471-6513
Practice Address - Street 1:2017 W I 35 FRONTAGE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8504
Practice Address - Country:US
Practice Address - Phone:405-757-3630
Practice Address - Fax:405-757-3631
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26519208100000X, 2081S0010X
IL036-115728208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115728Medicaid
I62743Medicare UPIN
ILK31492Medicare PIN
ILK35763Medicare PIN
ILK31491Medicare PIN