Provider Demographics
NPI:1003904129
Name:LAWRENCE, RYA ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:RYA
Middle Name:ELISABETH
Last Name:LAWRENCE
Suffix:
Gender:F
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-791-0075
Mailing Address - Fax:109-791-9674
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-791-0075
Practice Address - Fax:910-791-9674
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004774OtherPHYSICIAN'S ASSITANT LIC#