Healthcare Provider Details

I. General information

NPI: 1154717775
Provider Name (Legal Business Name): BENJAMIN LAWSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MULLAN RD STE 103A
MISSOULA MT
59808-5168
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-213-8939
  • Fax: 406-224-6127
Mailing address:
  • Phone: 866-747-2455
  • Fax: 406-329-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number172648
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMED-PHYS-LIC-126508
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: