Healthcare Provider Details

I. General information

NPI: 1164343182
Provider Name (Legal Business Name): MR. HAGAN COY LAWSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5534 SAINT JOE RD
FORT WAYNE IN
46835-3328
US

IV. Provider business mailing address

723 W FRANKLIN ST
WINCHESTER IN
47394-1412
US

V. Phone/Fax

Practice location:
  • Phone: 765-546-2506
  • Fax:
Mailing address:
  • Phone: 765-546-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28293387A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: