Provider Demographics
NPI:1679311054
Name:FRASER, DAVID THOMAS JR (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:FRASER
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:EAST WILLISTON
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2501
Mailing Address - Country:US
Mailing Address - Phone:516-241-3120
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant