Provider Demographics
NPI:1164017679
Name:FAIRBANKS, BRAIDEN CLARK
Entity Type:Individual
Prefix:
First Name:BRAIDEN
Middle Name:CLARK
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:
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:480-721-1784
Mailing Address - Fax:
Practice Address - Street 1:349 E CORONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1525
Practice Address - Country:US
Practice Address - Phone:602-266-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program