Provider Demographics
NPI:1518938315
Name:FRAGA, MICHAEL A (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:FRAGA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:FRAGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:INC
Mailing Address - Street 1:3015 MISSION ARCH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8304
Mailing Address - Country:US
Mailing Address - Phone:707-494-1303
Mailing Address - Fax:
Practice Address - Street 1:1717 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2000
Practice Address - Country:US
Practice Address - Phone:575-623-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1041103G00000X
CA17169103TC0700X
CAPSY17169103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
82-1127321OtherEIN
CA0PL171691Medicare PIN
CA0PL171690Medicare PIN
CA0PL171692Medicare PIN