Provider Demographics
NPI:1295467447
Name:FRYER, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FRYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15101 FAIRFIELD RANCH RD UNIT 14303
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-8891
Mailing Address - Country:US
Mailing Address - Phone:480-628-2692
Mailing Address - Fax:
Practice Address - Street 1:341 MAGNOLIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3331
Practice Address - Country:US
Practice Address - Phone:951-735-6060
Practice Address - Fax:951-735-4510
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant