Basic Information
| Provider Information | |||||||||
| NPI: | 1316384183 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRIDY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | GRAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S 8TH ST STE 284W | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707621792 | ||||||||
| FaxNumber: | 2707621783 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 8TH ST STE 284W | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707615756 | ||||||||
| FaxNumber: | 2707522856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 09/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1814 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100254610 | 05 | KY | MEDICAID |