Provider Demographics
NPI:1023032141
Name:FRY, JACK ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ROBERT
Last Name:FRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:963 NEIL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3434
Mailing Address - Country:US
Mailing Address - Phone:614-299-0902
Mailing Address - Fax:
Practice Address - Street 1:7333 SMITHS MILL RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-9291
Practice Address - Country:US
Practice Address - Phone:614-775-6675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN161169367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2044719Medicaid
OH8206989Medicare ID - Type Unspecified