Provider Demographics
NPI:1427024454
Name:FRY, DOUGLAS E (CRNP)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:E
Last Name:FRY
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2011
Mailing Address - Country:US
Mailing Address - Phone:610-940-2604
Mailing Address - Fax:610-940-2605
Practice Address - Street 1:231 AVON RD
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072
Practice Address - Country:US
Practice Address - Phone:267-263-0657
Practice Address - Fax:267-263-0667
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN247115L163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7660353Medicaid
035515Medicare ID - Type Unspecified
PA7660353Medicaid