Healthcare Provider Details

I. General information

NPI: 1174892590
Provider Name (Legal Business Name): PAWNEE HEALTH & WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 BOULDER ST
PAWNEE OK
74058-4028
US

IV. Provider business mailing address

304 BOULDER ST
PAWNEE OK
74058-4028
US

V. Phone/Fax

Practice location:
  • Phone: 918-762-3601
  • Fax: 918-762-2544
Mailing address:
  • Phone: 918-762-3601
  • Fax: 918-762-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOK1532
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA763
License Number StateOK

VIII. Authorized Official

Name: DR. GORDON PAGE LAIRD
Title or Position: OWNER
Credential: D.O.
Phone: 918-762-3601