Provider Demographics
NPI:1417575549
Name:FRYE, TARA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:FRYE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:78 OMEGA DR BLDG C
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2064
Mailing Address - Country:US
Mailing Address - Phone:302-368-2883
Mailing Address - Fax:302-368-2892
Practice Address - Street 1:78 OMEGA DR BLDG C
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2064
Practice Address - Country:US
Practice Address - Phone:302-368-2883
Practice Address - Fax:302-368-2892
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50011410363AM0700X
DEC5-0011410363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC50011410OtherSTATE LICENSE