Provider Demographics
NPI:1003830225
Name:LAWRENCE, SCOTT CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHARLES
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-459-3551
Mailing Address - Fax:616-459-1060
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-459-3551
Practice Address - Fax:616-459-1060
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISL004357363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16045Medicare ID - Type Unspecified
MIQ23602Medicare UPIN