MEDICARE: DANIELLE FAIRBANKS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	8028	AZ

General Provider Information

NPI Number	:	1083232177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE FAIRBANKS PA-C

Provider Business Mailing Address
First Line	:	253 N PIEDRA
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-7561
Country	:	US
Telephone Number	:	262-366-0419
Fax Number	:

Provider Business Practice Location Address
First Line	:	1744 S VAL VISTA DR STE 5-108
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-7362
Country	:	US
Telephone Number	:	888-663-6631
Fax Number	:	415-252-7176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2020
Last Update Date	:	03/17/2025

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