Provider Demographics
NPI:1174892590
Name:PAWNEE HEALTH & WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:PAWNEE HEALTH & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-762-3601
Mailing Address - Street 1:304 BOULDER ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-4028
Mailing Address - Country:US
Mailing Address - Phone:918-762-3601
Mailing Address - Fax:918-762-2544
Practice Address - Street 1:304 BOULDER ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-4028
Practice Address - Country:US
Practice Address - Phone:918-762-3601
Practice Address - Fax:918-762-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA763363A00000X
OKOK1532208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty