Basic Information
| Provider Information | |||||||||
| NPI: | 1215026760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRASER | ||||||||
| FirstName: | COSMO | ||||||||
| MiddleName: | LYLE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE | ||||||||
| Address2: | STE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 E ONSTOTT RD | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959911556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307510339 | ||||||||
| FaxNumber: | 5307510449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | C40203 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00C402030 | 05 | CA | MEDICAID |