Provider Demographics
NPI:1386622835
Name:FRALEY, JONATHAN G (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:FRALEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:MILE 187 GLENN HIGHWAY
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0005
Mailing Address - Country:US
Mailing Address - Phone:907-822-3203
Mailing Address - Fax:907-822-5805
Practice Address - Street 1:2730 ALASKA HIGHWAY
Practice Address - Street 2:
Practice Address - City:DELTA JUNCTION
Practice Address - State:AK
Practice Address - Zip Code:99737-0285
Practice Address - Country:US
Practice Address - Phone:907-895-6233
Practice Address - Fax:907-895-6288
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002345363A00000X
AK1197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA25814OtherMEDICARE PTAN
OHPA25815OtherMEDICARE PTAN
OH0075450Medicaid
OHPA25814OtherMEDICARE PTAN
OHQ55323Medicare UPIN