Basic Information
| Provider Information | |||||||||
| NPI: | 1629232681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRYDRYCH | ||||||||
| FirstName: | TERA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KILGORE | ||||||||
| OtherFirstName: | TERA | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 621 KELLY BLVD | ||||||||
| Address2: | PO BOX 143 | ||||||||
| City: | SLIPPERY ROCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160578523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247944009 | ||||||||
| FaxNumber: | 7247944099 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 KELLY BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIPPERY ROCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160578523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247944009 | ||||||||
| FaxNumber: | 7247944099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 06/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA053134 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.