Provider Demographics
NPI:1750702288
Name:FRASURE, TIFFANY J (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:FRASURE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:J
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-617-1227
Mailing Address - Fax:702-492-9574
Practice Address - Street 1:2845 SIENA HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4153
Practice Address - Country:US
Practice Address - Phone:702-617-1227
Practice Address - Fax:702-492-9574
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1478363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750702288Medicaid
NVV109814Medicare PIN