Provider Demographics
NPI:1023703923
Name:FRY, JASON JOHN (CRNA, DNP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
Last Name:FRY
Suffix:
Gender:
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 E PALM AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-6279
Mailing Address - Country:US
Mailing Address - Phone:801-529-2326
Mailing Address - Fax:801-529-2326
Practice Address - Street 1:11234 ANDERSON ST STE A504
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:909-558-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002584367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered