Provider Demographics
NPI:1699131110
Name:CMC
Entity type:Organization
Organization Name:CMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-507-7000
Mailing Address - Street 1:1801 E MARCH LN STE D470
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6677
Mailing Address - Country:US
Mailing Address - Phone:209-507-7000
Mailing Address - Fax:209-507-7550
Practice Address - Street 1:1801 E MARCH LN STE D470
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6677
Practice Address - Country:US
Practice Address - Phone:209-507-7000
Practice Address - Fax:209-507-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22498363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty