Provider Demographics
NPI:1255322640
Name:FRY, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:1520 VIRGINIA RANCH ROAD
Practice Address - Street 2:SUITE 101B
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5731
Practice Address - Country:US
Practice Address - Phone:775-782-2442
Practice Address - Fax:775-782-7205
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54590207X00000X
NV6420207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002003052Medicaid
CA00G545900OtherMEDI-CAL
CA200034256OtherMEDICARE RAILROAD
NVP00343660OtherMEDICARE RAILROAD
NVCC6619OtherBCBS
CA00G545901Medicare PIN
CA200034256OtherMEDICARE RAILROAD
NVP00343660OtherMEDICARE RAILROAD
CA00G545900OtherMEDI-CAL