Provider Demographics
NPI:1417467036
Name:FRIED, ZACHARY WYATT (ATC)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:WYATT
Last Name:FRIED
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-3431
Mailing Address - Country:US
Mailing Address - Phone:908-577-8006
Mailing Address - Fax:
Practice Address - Street 1:250 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:PA
Practice Address - Zip Code:15419-1341
Practice Address - Country:US
Practice Address - Phone:724-938-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0067372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer