Provider Demographics
NPI:1134901846
Name:FAIRBANKS, TRAVIS EDWARD (DNP)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:EDWARD
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W MAGNETIC ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2747
Mailing Address - Country:US
Mailing Address - Phone:906-399-3077
Mailing Address - Fax:
Practice Address - Street 1:3401 LUDINGTON ST
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1300
Practice Address - Country:US
Practice Address - Phone:906-786-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF04230411363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily