Basic Information
| Provider Information | |||||||||
| NPI: | 1598982324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CLINIC AT PANORAMA CITY,PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4044 15TH LN SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604914460 | ||||||||
| FaxNumber: | 3604913090 | ||||||||
| Practice Location | |||||||||
| Address1: | 4044 15TH LN SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604914460 | ||||||||
| FaxNumber: | 3604913090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FAIRBROOK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3604914460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RG0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 363LF0000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.