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General NPI Number Information
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NPI Number | 1336565431
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Entity Type | Individual
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Provider Name | TIMOTHY CHAD FRYE CRNP
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Gender | Male
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Dates
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Enumeration Date | 03/13/2014
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Last Update Date | 09/16/2024
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Provider Practice Location Address
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Address Line | 15024 MARTIN LUTHER KING JR BLVD
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City | GULFPORT
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State | MS
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Zip | 39501-8306
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Country | US
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Telephone | 205-783-7970
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Fax | 205-783-7695
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Provider Business Mailing Address
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Address Line | 10467 CORPORATE DR
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City | GULFPORT
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State | MS
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Zip | 39503-4634
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Country | US
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Telephone | 228-374-2494
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1-117395
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License Number State | AL
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