Provider Demographics
NPI:1629232681
Name:FRYDRYCH, TERA S (PA-C)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:S
Last Name:FRYDRYCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:S
Other - Last Name:KILGORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:621 KELLY BLVD
Mailing Address - Street 2:PO BOX 143
Mailing Address - City:SLIPPERY ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:16057-8523
Mailing Address - Country:US
Mailing Address - Phone:724-794-4009
Mailing Address - Fax:724-794-4099
Practice Address - Street 1:621 KELLY BLVD
Practice Address - Street 2:
Practice Address - City:SLIPPERY ROCK
Practice Address - State:PA
Practice Address - Zip Code:16057-8523
Practice Address - Country:US
Practice Address - Phone:724-794-4009
Practice Address - Fax:724-794-4099
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical