Provider Demographics
NPI:1518074178
Name:FRY, ROBIN ALAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:ALAN
Last Name:FRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6386 GREELEY HILL ROAD
Mailing Address - Street 2:NORTHSIDE CLINIC
Mailing Address - City:COULTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95311
Mailing Address - Country:US
Mailing Address - Phone:209-878-0155
Mailing Address - Fax:209-878-0145
Practice Address - Street 1:6386 GREELEY HILL RD
Practice Address - Street 2:NORTHSIDE CLINIC
Practice Address - City:COULTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95311
Practice Address - Country:US
Practice Address - Phone:209-878-0155
Practice Address - Fax:209-878-0145
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPENDINGMedicaid
MTPENDINGMedicare ID - Type Unspecified
MTPENDINGMedicaid