Basic Information
| Provider Information | |||||||||
| NPI: | 1326046913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWSON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 N MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426290966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703432597 | ||||||||
| FaxNumber: | 2703432598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
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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 | 207Q00000X | 33028 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64330285 | 05 | KY | MEDICAID |