Provider Demographics
NPI:1003494899
Name:FRYER GORDON, REBECCA LYNN (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:FRYER GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:FRYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:600 BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8022
Mailing Address - Country:US
Mailing Address - Phone:573-364-8822
Mailing Address - Fax:573-202-2402
Practice Address - Street 1:600 BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8022
Practice Address - Country:US
Practice Address - Phone:573-364-8822
Practice Address - Fax:573-202-2402
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023020151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program