Provider Demographics
NPI:1245204346
Name:FAIR, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:FAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 MAIN STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330
Mailing Address - Country:US
Mailing Address - Phone:763-241-5805
Mailing Address - Fax:763-241-5835
Practice Address - Street 1:290 MAIN ST NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1270
Practice Address - Country:US
Practice Address - Phone:763-241-5805
Practice Address - Fax:763-241-5835
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN053470600Medicaid
I15051Medicare UPIN
MN053470600Medicaid