Provider Demographics
NPI:1972146041
Name:FAIRBANKS, ROBERT
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
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 1:1502 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-4324
Mailing Address - Country:US
Mailing Address - Phone:218-847-3456
Mailing Address - Fax:
Practice Address - Street 1:1502 WILLARD AVE # A
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-4324
Practice Address - Country:US
Practice Address - Phone:218-847-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA598473100OtherUMPI