Healthcare Provider Details

I. General information

NPI: 1699903559
Provider Name (Legal Business Name): KEITH A FAIRBANKS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10452 SILVERDALE WAY NW
SILVERDALE WA
98383-9411
US

IV. Provider business mailing address

10452 SILVERDALE WAY NW
SILVERDALE WA
98383-9411
US

V. Phone/Fax

Practice location:
  • Phone: 360-307-7300
  • Fax: 360-307-7304
Mailing address:
  • Phone: 360-307-7300
  • Fax: 360-307-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102202929
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61057968
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: