Provider Demographics
NPI:1205927613
Name:FRATTALI, JEFFREY SCOTT (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:FRATTALI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:SCOTT
Other - Last Name:FRATTALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:209-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:10910 LITTLE PATUXENT PKWY STE 205
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3092
Practice Address - Country:US
Practice Address - Phone:410-772-0707
Practice Address - Fax:410-772-5654
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002283363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ53591Medicare UPIN
MD483MM601Medicare ID - Type Unspecified