Provider Demographics
NPI:1679765192
Name:FRASER, BRIAN J (PATHOLOGY ASSISTANT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:FRASER
Suffix:
Gender:M
Credentials:PATHOLOGY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0401
Mailing Address - Country:US
Mailing Address - Phone:605-333-1720
Mailing Address - Fax:605-333-1966
Practice Address - Street 1:1305 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-333-1720
Practice Address - Fax:605-333-1966
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0058207ZP0101X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0058OtherPHYSICIAN ASSISTANT CERTI