Provider Demographics
NPI:1679880504
Name:FAIRBANKS, EVAN THOMAS
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:THOMAS
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BLAISDELL STREET
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-5425
Mailing Address - Country:US
Mailing Address - Phone:978-994-7423
Mailing Address - Fax:
Practice Address - Street 1:4 BLAISDELL ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01832-5425
Practice Address - Country:US
Practice Address - Phone:978-994-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker