Provider Demographics
NPI:1770190456
Name:LAIRD, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LAIRD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:AZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10701 KNIGHTSBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9157
Mailing Address - Country:US
Mailing Address - Phone:443-867-2748
Mailing Address - Fax:
Practice Address - Street 1:3524 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4486
Practice Address - Country:US
Practice Address - Phone:317-925-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003075A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant