MEDICARE: AMANDA N LAWRENCE 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	2011005771	MO

General Provider Information

NPI Number	:	1295026631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA N LAWRENCE PA-C

Provider Business Mailing Address
First Line	:	16759 MAIN ST
Second Line	:	STE. 201
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1232
Country	:	US
Telephone Number	:	636-821-1661
Fax Number	:	636-821-1665

Provider Business Practice Location Address
First Line	:	16759 MAIN ST
Second Line	:	STE. 201
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1232
Country	:	US
Telephone Number	:	636-821-1661
Fax Number	:	636-821-1665

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

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	01/18/2017

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