Basic Information
| Provider Information | |||||||||
| NPI: | 1538418793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRBANKS | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1235 E CHEROKEE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202829 | ||||||||
| FaxNumber: | 4178208852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2012 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2012028957 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1538418793 | 05 | MO | MEDICAID | P01129106 | 01 | MO | RR MCR | OTHER | 431560263 | 01 | MO | TRICARE | OTHER |