Basic Information
| Provider Information | |||||||||
| NPI: | 1164017679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRBANKS | ||||||||
| FirstName: | BRAIDEN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5302 E VAN BUREN ST UNIT 3021 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850087975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807211784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 349 E CORONADO RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022665678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2021 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.