Provider Demographics
NPI:1861821837
Name:FAIRBANK, JULIA (PA)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3431
Mailing Address - Country:US
Mailing Address - Phone:307-332-2941
Mailing Address - Fax:307-332-1920
Practice Address - Street 1:745 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-332-2941
Practice Address - Fax:307-332-1920
Is Sole Proprietor?:No
Enumeration Date:2013-11-10
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY585363A00000X
CO3738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant