Provider Demographics
NPI:1083232177
Name:FAIRBANKS, DANIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 N PIEDRA
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-7561
Mailing Address - Country:US
Mailing Address - Phone:262-366-0419
Mailing Address - Fax:
Practice Address - Street 1:1744 S VAL VISTA DR STE 5-108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7362
Practice Address - Country:US
Practice Address - Phone:888-663-6631
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ8028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant