Provider Demographics
NPI:1639178080
Name:FRERICH, CARYLON (PA)
Entity Type:Individual
Prefix:
First Name:CARYLON
Middle Name:
Last Name:FRERICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W 11TH PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-4119
Mailing Address - Country:US
Mailing Address - Phone:432-263-6018
Mailing Address - Fax:
Practice Address - Street 1:1501 W 11TH PL
Practice Address - Street 2:SUITE 102
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-4119
Practice Address - Country:US
Practice Address - Phone:432-263-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184362501Medicaid
TX8N4712OtherBCBS OF TX
TX184362501Medicaid