Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 036-115728 | IL |
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 26519 | OK |
Y | 2081S0010X | Sports Medicine | 26519 | OK |
Y | 213ES0000X | Sports Medicine | 26519 | OK |
NPI | 1487660585 |
---|---|
Provider Name | Andrea Fraley |
First Address | Edmond, OK 73034-7399 |
Second Address | Edmond, OK 73013-8504 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 11/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036115728 | (05) | IL |
I62743 | (02) |