Provider Demographics
NPI:1972547586
Name:FRY, LESLIE (PA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0717
Mailing Address - Country:US
Mailing Address - Phone:973-740-0607
Mailing Address - Fax:
Practice Address - Street 1:SOMERSET MEDICAL CENTER
Practice Address - Street 2:110 REHILL AVENUE
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00025000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ003710Medicare ID - Type Unspecified
S52183Medicare UPIN