Provider Demographics
NPI:1760648117
Name:FRASER-GRAY, MIKHAIL WENUTU (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:WENUTU
Last Name:FRASER-GRAY
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:111 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6861
Mailing Address - Country:US
Mailing Address - Phone:310-379-2134
Mailing Address - Fax:310-379-4856
Practice Address - Street 1:869 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2207
Practice Address - Country:US
Practice Address - Phone:559-688-0821
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2021-12-06
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Provider Licenses
StateLicense IDTaxonomies
CA19766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant