Basic Information
| Provider Information | |||||||||
| NPI: | 1750702288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRASURE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BATES | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026171227 | ||||||||
| FaxNumber: | 7024929574 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 SIENA HEIGHTS DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026171227 | ||||||||
| FaxNumber: | 7024929574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2013 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1478 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1750702288 | 05 | NV | MEDICAID |