Provider Demographics
NPI:1811909609
Name:FRY, JENA L (PA-C)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:L
Last Name:FRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5128
Mailing Address - Country:US
Mailing Address - Phone:620-275-1766
Mailing Address - Fax:
Practice Address - Street 1:712 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5128
Practice Address - Country:US
Practice Address - Phone:620-275-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500856363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100450410AMedicaid
KSK33C127Medicare ID - Type Unspecified
KS100450410AMedicaid