Basic Information
| Provider Information | |||||||||
| NPI: | 1194702407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREY | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 5TH ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150091964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247745255 | ||||||||
| FaxNumber: | 7247745686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07816721 | 05 | PA | MEDICAID |