Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 64281 | MN |
N | 207QA0401X | Family Doctor - Addiction Medicine | 64281 | MN |
NPI | 1770016453 |
---|---|
Provider Name | Jeremiah Douglas Fairbanks |
First Address | Hastings, MN 55033-2687 |
Second Address | Hastings, MN 55033-2687 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2017 |
Last Update Date | 25/01/2022 |