MEDICARE: MARK T STLAWRENCE PA

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9103599	FL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	L4724	OTHER	FL	MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y0R4E	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1962446377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK T STLAWRENCE PA

Provider Business Mailing Address
First Line	:	2675 WINKLER AVE FL 2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9342
Country	:	US
Telephone Number	:	877-856-3774
Fax Number	:

Provider Business Practice Location Address
First Line	:	7751 BYAMEADOWS RD E
Second Line	:	SUITE H
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-5836
Country	:	US
Telephone Number	:	904-425-6963
Fax Number	:	904-674-0155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/31/2020

7751 BAYMEADOWS RD E STE G
JACKSONVILLE, FL
32256-5836

Practice Phone: 904-420-6202
Practice Fax: 904-420-6203

7751 BAYMEADOWS RD E STE H
JACKSONVILLE, FL
32256-5836