Healthcare Provider Details

I. General information

NPI: 1710698030
Provider Name (Legal Business Name): LAWRENCE CIVIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ERIE BLVD
CANAJOHARIE NY
13317-1133
US

IV. Provider business mailing address

48 ERIE BLVD
CANAJOHARIE NY
13317-1133
US

V. Phone/Fax

Practice location:
  • Phone: 518-673-2573
  • Fax: 518-673-2781
Mailing address:
  • Phone: 518-673-2573
  • Fax: 518-673-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: