Provider Demographics
NPI:1346514973
Name:FAIRCHILD, CARRIE B (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:PA
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 931267
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-1484
Mailing Address - Country:US
Mailing Address - Phone:937-383-1040
Mailing Address - Fax:
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2125
Practice Address - Country:US
Practice Address - Phone:937-383-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant