Provider Demographics
NPI:1144213588
Name:BONZER-FRY, GAYLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:
Last Name:BONZER-FRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:GAYLE
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:HORSESHOE BEND
Mailing Address - State:ID
Mailing Address - Zip Code:83629-0205
Mailing Address - Country:US
Mailing Address - Phone:208-793-3333
Mailing Address - Fax:208-793-3666
Practice Address - Street 1:400 HIGHWAY 55
Practice Address - Street 2:SUITE A
Practice Address - City:HORSESHOE BEND
Practice Address - State:ID
Practice Address - Zip Code:83629-9015
Practice Address - Country:US
Practice Address - Phone:208-793-3333
Practice Address - Fax:208-793-6333
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010008652OtherBLUE SHIELD
IDT0239OtherBLUE CROSS OF IDAHO
ID804131800Medicaid
IDT0239OtherBLUE CROSS OF IDAHO