Healthcare Provider Details

I. General information

NPI: 1154528792
Provider Name (Legal Business Name): LAURA L LAWRENCE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 12/07/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

IV. Provider business mailing address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1018
  • Fax:
Mailing address:
  • Phone: 208-422-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA05010
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: