Basic Information
| Provider Information | |||||||||
| NPI: | 1558380659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRY | ||||||||
| FirstName: | SHAON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 BERRYWOOD DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734498771 | ||||||||
| FaxNumber: | 5734496563 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 E NIFONG BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652033759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737776955 | ||||||||
| FaxNumber: | 5737776957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 109173 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.