Provider Demographics
NPI:1679635841
Name:FAIR, BYRON W (PT)
Entity Type:Individual
Prefix:MR
First Name:BYRON
Middle Name:W
Last Name:FAIR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1054 HIGHLAND COVE PL
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1523
Mailing Address - Country:US
Mailing Address - Phone:601-636-6019
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:2475 LAKELAND DR STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9505
Practice Address - Country:US
Practice Address - Phone:601-636-6019
Practice Address - Fax:601-661-8457
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist