MEDICARE: NAOMI RUTH LAIRD PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	68042761206	UT

General Provider Information

NPI Number	:	1053303420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAOMI RUTH LAIRD PA-C

Provider Business Mailing Address
First Line	:	590 S WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-587-7109
Fax Number	:	801-587-7117

Provider Business Practice Location Address
First Line	:	590 S WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-587-7109
Fax Number	:	801-587-7117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	11/17/2021

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Directions to “ NAOMI RUTH LAIRD PA-C” Practice Location

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