Provider Demographics
NPI:1639759954
Name:FRAZIER, LIANA (PA-C, RD, LDN)
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:PA-C, RD, LDN
Other - Prefix:
Other - First Name:LIANA
Other - Middle Name:
Other - Last Name:BROCKWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:860-798-0268
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2632
Practice Address - Country:US
Practice Address - Phone:860-798-0268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1183264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program