Provider Demographics
NPI:1023068004
Name:FAIR, MAGGIE MARTIN (FNP)
Entity type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:MARTIN
Last Name:FAIR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILBURN WAY
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3693
Mailing Address - Country:US
Mailing Address - Phone:662-323-9908
Mailing Address - Fax:662-323-8948
Practice Address - Street 1:101 WILBURN WAY
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3693
Practice Address - Country:US
Practice Address - Phone:662-323-9908
Practice Address - Fax:662-323-8948
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860376363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02906593Medicaid
MS02906593Medicaid
MS500001755Medicare ID - Type Unspecified