1235193749 NPI number — SARAH J FRY LMP

Table of content: SARAH J FRY LMP (NPI 1235193749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235193749 NPI number — SARAH J FRY LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRY
Provider First Name:
SARAH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VILES
Provider Other First Name:
SARAH
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235193749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 731269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98373-0060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-840-2313
Provider Business Mailing Address Fax Number:
253-840-6340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3912 10TH ST SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374-2188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-848-4700
Provider Business Practice Location Address Fax Number:
253-848-2284
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00017811 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2351VI . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8934966 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 170745 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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