Provider Demographics
NPI:1801297379
Name:FAIRHART, JOHN PAUL MARCEL (DPT)
Entity type:Individual
Prefix:
First Name:JOHN PAUL
Middle Name:MARCEL
Last Name:FAIRHART
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 AVERY LN SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5603
Mailing Address - Country:US
Mailing Address - Phone:360-736-5273
Mailing Address - Fax:360-736-5053
Practice Address - Street 1:1118 VIEW AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1870
Practice Address - Country:US
Practice Address - Phone:360-736-5273
Practice Address - Fax:360-736-5053
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60482042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist