Provider Demographics
NPI:1588635197
Name:FAIRBANK, JOAN (PT)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 WINTHROP DR
Mailing Address - Street 2:#4
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-844-3440
Practice Address - Fax:607-844-3779
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0265801174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5577Medicare ID - Type Unspecified
NYQ34738Medicare UPIN