Healthcare Provider Details

I. General information

NPI: 1932011418
Provider Name (Legal Business Name): FAIRWATER FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 W 21ST ST STE 202
NORFOLK VA
23517-2130
US

IV. Provider business mailing address

327 W 21ST ST STE 202
NORFOLK VA
23517-2130
US

V. Phone/Fax

Practice location:
  • Phone: 757-876-9788
  • Fax:
Mailing address:
  • Phone: 757-271-4593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEVON SHICK
Title or Position: OWNER
Credential: MD
Phone: 757-271-4593