Provider Demographics
NPI:1841540721
Name:FRASER, JACKSON (PA)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:FRASER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28720 ROADSIDE DR
Mailing Address - Street 2:SUITE 399
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-3316
Mailing Address - Country:US
Mailing Address - Phone:818-575-9501
Mailing Address - Fax:818-575-9052
Practice Address - Street 1:28720 ROADSIDE DR
Practice Address - Street 2:SUITE 399
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-3316
Practice Address - Country:US
Practice Address - Phone:818-575-9501
Practice Address - Fax:818-575-9052
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGS079ZMedicare PIN