Healthcare Provider Details

I. General information

NPI: 1477168565
Provider Name (Legal Business Name): CODY WAYNE LAWSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1350
US

IV. Provider business mailing address

115 2ND AVE S APT 701
MINNEAPOLIS MN
55401-2014
US

V. Phone/Fax

Practice location:
  • Phone: 612-330-1000
  • Fax:
Mailing address:
  • Phone: 276-618-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: