Provider Demographics
NPI:1710900717
Name:FAIRBANKS, BRET SNYDER (PT)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:SNYDER
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PETERS CANYON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1798
Mailing Address - Country:US
Mailing Address - Phone:949-679-3988
Mailing Address - Fax:949-679-7665
Practice Address - Street 1:2 PETERS CANYON RD STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-1798
Practice Address - Country:US
Practice Address - Phone:949-679-3988
Practice Address - Fax:949-679-7665
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 24608OtherPHYSICAL THERAPY LICENSE
CAPT 24608OtherPHYSICAL THERAPY LICENSE