Provider Demographics
NPI:1013056357
Name:FAIRBANKS, GRANT ANDREAS (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:ANDREAS
Last Name:FAIRBANKS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10382 S JORDAN GTWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4135
Mailing Address - Country:US
Mailing Address - Phone:801-951-8099
Mailing Address - Fax:801-951-8098
Practice Address - Street 1:10382 S JORDAN GTWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4135
Practice Address - Country:US
Practice Address - Phone:801-951-8099
Practice Address - Fax:801-951-8098
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2744901205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005817901Medicare ID - Type Unspecified
I50103Medicare UPIN