Healthcare Provider Details

I. General information

NPI: 1912994252
Provider Name (Legal Business Name): MARK ALLEN LAWRENCE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JCT US HWY 160 & NAVAJO ROUTE 35 RED MESA
TEECNOSPOS AZ
86514
US

IV. Provider business mailing address

HCR 6100 BOX 30
TEECNOSPOS AZ
86514
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5165
  • Fax: 928-656-5164
Mailing address:
  • Phone: 928-656-5165
  • Fax: 928-656-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: