Basic Information
| Provider Information | |||||||||
| NPI: | 1003830225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 CHERRY ST SE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164593551 | ||||||||
| FaxNumber: | 6164591060 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 CHERRY ST SE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164593551 | ||||||||
| FaxNumber: | 6164591060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | SL004357 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.