Provider Demographics
NPI:1558826719
Name:LAIRD, ELLERY (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLERY
Middle Name:
Last Name:LAIRD
Suffix:
Gender:F
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 1:524 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-1110
Mailing Address - Country:US
Mailing Address - Phone:616-403-1375
Mailing Address - Fax:
Practice Address - Street 1:77 MORAGA WAY STE G
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3019
Practice Address - Country:US
Practice Address - Phone:925-254-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009995363A00000X
CAPA56519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant