Provider Demographics
NPI:1801832373
Name:FAIRLEY, DAWN A (DO)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:A
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63565-1642
Mailing Address - Country:US
Mailing Address - Phone:660-947-2300
Mailing Address - Fax:660-947-2307
Practice Address - Street 1:103 S 18TH ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1642
Practice Address - Country:US
Practice Address - Phone:660-947-2300
Practice Address - Fax:660-947-2307
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012469207Q00000X
MO2006023529207Q00000X
CA20A 7187207Q00000X
FLOS 9881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207348905Medicaid
PA0019478700001Medicaid
MO961950085OtherMEDICARE ID - TYPE UNSPECIFIED
MOC24545Medicare UPIN
MO961950085OtherMEDICARE ID - TYPE UNSPECIFIED
PA065575Medicare ID - Type UnspecifiedMEDICARE