Provider Demographics
NPI:1700424256
Name:FRYAR, MICA DESHAUN
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:DESHAUN
Last Name:FRYAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7193 FEATHER CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5107
Mailing Address - Country:US
Mailing Address - Phone:614-352-9473
Mailing Address - Fax:
Practice Address - Street 1:2017 E MAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-8164
Practice Address - Country:US
Practice Address - Phone:614-352-9473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker