Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 2744901205 | UT |
Y | 208600000X | Surgeon | 2744901205 | UT |
NPI | 1013056357 |
---|---|
Provider Name | Dr. Grant Andreas Fairbanks |
First Address | Bountiful, UT 84010-8903 |
Second Address | Salt Lake City, UT 84124 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 24/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I50103 | (02) |