Provider Demographics
NPI:1053340646
Name:FRYE, WENDY AMBER (MD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:AMBER
Last Name:FRYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ST. JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:989-731-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082602208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4785784Medicaid
MI0F96004OtherMEDICARE GROUP ID
MI0206910342OtherBCBSM PROVIDER NUMBER
11276527OtherCAQH PROVIDER ID
CC4805OtherMEDICARE RR PROV ID
MI4785784Medicaid