MEDICARE: ELLERY 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	5601009995	MI
2	363A00000X	Physician Assistant	PA56519	CA
3	363A00000X	Physician Assistant	PA6499	TN

General Provider Information

NPI Number	:	1558826719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLERY LAIRD PA-C

Provider Business Mailing Address
First Line	:	524 N 5TH AVE
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-1110
Country	:	US
Telephone Number	:	616-403-1375
Fax Number	:

Provider Business Practice Location Address
First Line	:	6216 HIGHLAND PLACE WAY STE 102
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-4068
Country	:	US
Telephone Number	:	865-888-9958
Fax Number	:	440-582-3171

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

Provider Enumeration Date	:	02/01/2019
Last Update Date	:	08/12/2025

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Directions to “ ELLERY LAIRD PA-C” Practice Location

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