Provider Demographics
NPI:1285613919
Name:FRY-MILLER, PAUL H (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:FRY-MILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:H
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3702 NEW VISION DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-8211
Mailing Address - Fax:260-458-5641
Practice Address - Street 1:1104 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1001
Practice Address - Country:US
Practice Address - Phone:260-982-2102
Practice Address - Fax:260-982-2105
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000057A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN221600DMedicare PIN
S57575Medicare UPIN