Provider Demographics
NPI:1255304598
Name:FAIRCHILD, MARK (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-796-6221
Practice Address - Street 1:211 KY 59
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-9701
Practice Address - Country:US
Practice Address - Phone:606-796-3029
Practice Address - Fax:606-796-6221
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002721Medicaid
KY95002721Medicaid
KY0055622Medicare PIN