Provider Demographics
NPI:1013217751
Name:FRY, KENT ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:ALAN
Last Name:FRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:2320 FREEWAY DRIVE
Practice Address - Street 2:SKAGIT REGIONAL CLINICS - RIVERBEND ORTHOPEDICS
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-814-6800
Practice Address - Fax:360-814-6917
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60188670363A00000X, 363AM0700X, 363AS0400X
ORPA158179363A00000X
SD0796363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1013217751Medicaid