Provider Demographics
NPI:1487393740
Name:FRASER, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FRASER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 NW 208TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-1900
Mailing Address - Country:US
Mailing Address - Phone:920-544-6202
Mailing Address - Fax:
Practice Address - Street 1:321 ROOD AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2420
Practice Address - Country:US
Practice Address - Phone:970-325-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL.0018396Medicaid