Provider Demographics
NPI:1336471374
Name:FAIRALL, WILLIAM LEE (SOIDC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEE
Last Name:FAIRALL
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8161 RED COCKADED CT APT 103
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7186
Mailing Address - Country:US
Mailing Address - Phone:443-521-1778
Mailing Address - Fax:
Practice Address - Street 1:8161 RED COCKADED CT APT 103
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-7186
Practice Address - Country:US
Practice Address - Phone:443-521-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman