Provider Demographics
NPI:1669984738
Name:FRAZIER, MICHAEL SHAWN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAWN
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-1139
Mailing Address - Country:US
Mailing Address - Phone:304-375-3635
Mailing Address - Fax:
Practice Address - Street 1:413 HENDERSON AVE.
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187
Practice Address - Country:US
Practice Address - Phone:304-375-3635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVG38100251823747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG3810025182Medicaid