Provider Demographics
NPI:1982670337
Name:ULTRA CLASSIC ANESTHESIA PA
Entity Type:Organization
Organization Name:ULTRA CLASSIC ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-664-6761
Mailing Address - Street 1:30 TOMAHAWK RD
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-2935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1105
Practice Address - Country:US
Practice Address - Phone:620-664-6761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3545OtherRAILROAD MEDICARE
KS180040Medicare ID - Type Unspecified