Basic Information
Provider Information | |||||||||
NPI: | 1568409324 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAIRD | ||||||||
FirstName: | SUNDAY | ||||||||
MiddleName: | NESBIT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NESBIT | ||||||||
OtherFirstName: | SUNDAY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 321 N WARREN ST | ||||||||
Address2: |   | ||||||||
City: | TRENTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 086184741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092785900 | ||||||||
FaxNumber: | 6096953532 | ||||||||
Practice Location | |||||||||
Address1: | 1005 MAR WALT DRIVE | ||||||||
Address2: | NURSING HOME DEPARTMENT | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325476796 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508638202 | ||||||||
FaxNumber: | 8508626148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 02/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103475 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.