Provider Demographics
NPI:1679620058
Name:LAIRD, TOMMY WAYNE JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:WAYNE
Last Name:LAIRD
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5 ADMIRALS CIR
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-6301
Mailing Address - Country:US
Mailing Address - Phone:512-540-1117
Mailing Address - Fax:254-732-0795
Practice Address - Street 1:5400 CROSSLAKE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6977
Practice Address - Country:US
Practice Address - Phone:254-420-2336
Practice Address - Fax:254-732-0795
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00157011OtherTEXAS DPS REGISTRATION NUMBER
TXPA03396OtherTEXAS PA LICENSE
1034587OtherNCCPA CERTIFICATION ID NUMBER
1034587OtherNCCPA CERTIFICATION ID NUMBER
TXPA03396OtherTEXAS PA LICENSE