MEDICARE: MARYSSA FAIRBANKS PA

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

General Provider Information

NPI Number	:	1891653804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYSSA FAIRBANKS PA

Provider Business Mailing Address
First Line	:	1739 E BEVERLY AVE STE 102
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3593
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1739 E BEVERLY AVE STE 102
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3593
Country	:	US
Telephone Number	:	928-681-8693
Fax Number	:

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

Provider Enumeration Date	:	01/10/2026
Last Update Date	:	01/10/2026

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1739 E BEVERLY AVE STE 102
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1427048008 — ANNIE MYOWIN CHANG-BURNS M.D.
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1205826880 — DONALD LYNN MORGAN D.O.
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1063492676 — TED EDWARD ZEGARRA M.D.
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Directions to “ MARYSSA FAIRBANKS PA” Practice Location

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