Provider Demographics
NPI:1508839226
Name:FRASER, TONYA MAE (PAC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MAE
Last Name:FRASER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-8760
Mailing Address - Fax:704-384-8783
Practice Address - Street 1:11304 HAWTHORNE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-384-8760
Practice Address - Fax:704-384-8783
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2755353Medicare ID - Type Unspecified
NCP75848Medicare UPIN
2755353BMedicare PIN