Provider Demographics
NPI:1841223997
Name:FRASER-FARMER, GAIL
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:FRASER-FARMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 GRANNY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2130
Mailing Address - Country:US
Mailing Address - Phone:631-698-3258
Mailing Address - Fax:631-698-3259
Practice Address - Street 1:180 GRANNY RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2130
Practice Address - Country:US
Practice Address - Phone:631-698-3258
Practice Address - Fax:631-698-3259
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216533173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02207252Medicaid
P00373777Medicare PIN
NY40S001Medicare ID - Type Unspecified
NYH59098Medicare UPIN