Basic Information
| Provider Information | |||||||||
| NPI: | 1760648117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRASER-GRAY | ||||||||
| FirstName: | MIKHAIL | ||||||||
| MiddleName: | WENUTU | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Practice Location | |||||||||
| Address1: | 869 N CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TULARE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932742207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596880821 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 19766 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.