Provider Demographics
NPI:1083232177
Name:FAIRBANKS, DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5302 E VAN BUREN ST UNIT 3021
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7975
Mailing Address - Country:US
Mailing Address - Phone:262-366-0419
Mailing Address - Fax:
Practice Address - Street 1:19555 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6813
Practice Address - Country:US
Practice Address - Phone:623-572-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant