Provider Demographics
NPI:1558380659
Name:FRY, SHAON D (PT)
Entity Type:Individual
Prefix:
First Name:SHAON
Middle Name:D
Last Name:FRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:202 E NIFONG BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3759
Practice Address - Country:US
Practice Address - Phone:573-777-6955
Practice Address - Fax:573-777-6957
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist