Provider Demographics
NPI:1194077305
Name:LAIRD-WILSON, JOSHUA WILLIAM (ANP)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:WILLIAM
Last Name:LAIRD-WILSON
Suffix:
Gender:
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:685 TWELVE BRIDGES DR STE B
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-8689
Practice Address - Country:US
Practice Address - Phone:916-408-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000250363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01363680OtherRR MEDICARE-DS9933
CACA128472 EFF 6/30/14Medicare PIN