Provider Demographics
NPI:1356388094
Name:FRYE, TRACI M (RN, FNP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:FRYE
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-5460
Mailing Address - Fax:
Practice Address - Street 1:100 N. EAST STREET
Practice Address - Street 2:
Practice Address - City:JOSEPH
Practice Address - State:OR
Practice Address - Zip Code:97846
Practice Address - Country:US
Practice Address - Phone:541-432-7777
Practice Address - Fax:541-432-7170
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR093000596N1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276679Medicaid
ORR102236Medicare ID - Type Unspecified
OR276679Medicaid