Healthcare Provider Details

I. General information

NPI: 1720776545
Provider Name (Legal Business Name): JUSTIN FRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 GLENN HENDREN DR
LIBERTY MO
64068-9625
US

IV. Provider business mailing address

12811 PLATTSBURG RD
KEARNEY MO
64060-8167
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-7200
  • Fax:
Mailing address:
  • Phone: 816-507-9876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number1720776545
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: