Provider Demographics
NPI:1518135748
Name:FRASER, AMANDA JEAN (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:FRASER
Suffix:
Gender:F
Credentials:PA
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:14 REGIONAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8850
Practice Address - Country:US
Practice Address - Phone:910-295-6661
Practice Address - Fax:910-295-6524
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02636363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCU839AOtherMEDICARE PTAN
NC1518135748Medicaid
NCNCU839BOtherMEDICARE PTAN