Provider Demographics
NPI:1508330150
Name:FRAGA, ANDRES MARCO (MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:MARCO
Last Name:FRAGA
Suffix:
Gender:M
Credentials:MSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 TIMBERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-4554
Mailing Address - Country:US
Mailing Address - Phone:954-909-3932
Mailing Address - Fax:
Practice Address - Street 1:7345 COURAGE WAY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1555
Practice Address - Country:US
Practice Address - Phone:423-602-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000025231363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health