Provider Demographics
NPI:1578229373
Name:FRYAR, MICHAEL D (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:FRYAR
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3877
Mailing Address - Country:US
Mailing Address - Phone:815-714-7171
Mailing Address - Fax:815-435-5080
Practice Address - Street 1:915 CLINGAN RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3729
Practice Address - Country:US
Practice Address - Phone:423-339-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily