Provider Demographics
NPI:1558799130
Name:FRASER, AMY (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FRASER
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:1250 HANCOCK ST FL 5
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4339
Mailing Address - Country:US
Mailing Address - Phone:617-421-2686
Mailing Address - Fax:617-774-0606
Practice Address - Street 1:1250 HANCOCK ST FL 5
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4339
Practice Address - Country:US
Practice Address - Phone:617-421-2686
Practice Address - Fax:617-774-0606
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2277691363LG0600X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology