MEDICARE: PAUL H. FRY-MILLER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10000057A	IN

General Provider Information

NPI Number	:	1285613919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL H. FRY-MILLER PA-C

Provider Business Mailing Address
First Line	:	3702 NEW VISION DR
Second Line	:	BLDG B
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1703
Country	:	US
Telephone Number	:	260-266-8211
Fax Number	:	260-458-5641

Provider Business Practice Location Address
First Line	:	1104 N WAYNE ST
Second Line	:
City	:	NORTH MANCHESTER
State	:	IN
Zip	:	46962-1001
Country	:	US
Telephone Number	:	260-982-2102
Fax Number	:	260-982-2105

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	01/15/2020

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