Provider Demographics
NPI:1528060126
Name:FRYAR, DOUGLAS (CRNA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FRYAR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W HAMLET AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-4522
Mailing Address - Country:US
Mailing Address - Phone:910-205-8245
Mailing Address - Fax:910-205-8164
Practice Address - Street 1:1000 W HAMLET AVE
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4522
Practice Address - Country:US
Practice Address - Phone:910-205-8245
Practice Address - Fax:910-205-8164
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC030988367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001717376OtherMTN STATE BCBS
VA8939420Medicaid
WV0065428000Medicaid
VA8939420Medicaid
VAR76961Medicare UPIN
VA430000262Medicare ID - Type Unspecified