Provider Demographics
NPI:1386075901
Name:FRY, NATHAN (ATC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FRY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BOYER AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2067
Mailing Address - Country:US
Mailing Address - Phone:509-527-5911
Mailing Address - Fax:509-527-5730
Practice Address - Street 1:345 BOYER AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2067
Practice Address - Country:US
Practice Address - Phone:509-527-5911
Practice Address - Fax:509-527-5730
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 601085702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer