Provider Demographics
NPI:1063543890
Name:FAIRCLOTH, JOHN MYRON (NP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MYRON
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:550 REDSTONE AVE W STE 460
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6428
Mailing Address - Country:US
Mailing Address - Phone:205-454-2022
Mailing Address - Fax:850-398-8727
Practice Address - Street 1:127 E REDSTONE AVE STE C
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5356
Practice Address - Country:US
Practice Address - Phone:850-423-0061
Practice Address - Fax:850-423-9954
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-09-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0103219363LF0000X
FLARNP9470257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000946547BMedicaid
GA000946547BMedicaid
GAP84612Medicare UPIN