Basic Information
| Provider Information | |||||||||
| NPI: | 1063408052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRFAX | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992100421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE STE 1400 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097442200 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10003111 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0166417 | 01 | WA | LABOR & INDUSTRIES | OTHER | 806204300 | 05 | ID | MEDICAID | 970030113 | 01 | RAILROAD MEDICARE | OTHER | 7628FA | 01 | WA | ASURIS NW HEALTH | OTHER | 8323370 | 05 | WA | MEDICAID | 000010142789 | 01 | BLUE SHIELD OF IDAHO | OTHER |