Provider Demographics
NPI:1104517416
Name:FRY, KEATON TYLER
Entity type:Individual
Prefix:
First Name:KEATON
Middle Name:TYLER
Last Name:FRY
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 1:17047 640TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-7822
Mailing Address - Country:US
Mailing Address - Phone:515-450-6169
Mailing Address - Fax:
Practice Address - Street 1:17047 640TH AVE
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201-7822
Practice Address - Country:US
Practice Address - Phone:515-450-6169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer