Healthcare Provider Details

I. General information

NPI: 1164017679
Provider Name (Legal Business Name): BRAIDEN CLARK FAIRBANKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 E CORONADO RD
PHOENIX AZ
85004-1525
US

IV. Provider business mailing address

253 N PIEDRA
MESA AZ
85207-7561
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5678
  • Fax:
Mailing address:
  • Phone: 480-721-1784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8690
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: