Provider Demographics
NPI:1174090393
Name:FAIRCHILD, BRENT WILLIAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:WILLIAM
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 BRIGHT STREAM WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580
Mailing Address - Country:US
Mailing Address - Phone:585-410-0678
Mailing Address - Fax:
Practice Address - Street 1:1081 BRIGHT STREAM WAY
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580
Practice Address - Country:US
Practice Address - Phone:585-410-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025179363A00000X
NY25179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant