Provider Demographics
NPI:1003202847
Name:FAIRBANKS, SHAN R (DO)
Entity Type:Individual
Prefix:
First Name:SHAN
Middle Name:R
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 625
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5516
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:118 BROAD ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3211
Practice Address - Country:US
Practice Address - Phone:540-674-8805
Practice Address - Fax:540-674-8670
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102204926207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine