Provider Demographics
NPI:1225514136
Name:MISSION FUNCTIONAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:MISSION FUNCTIONAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-247-8476
Mailing Address - Street 1:103 CHANCELLORSVILLE DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-4515
Mailing Address - Country:US
Mailing Address - Phone:540-247-8476
Mailing Address - Fax:
Practice Address - Street 1:230 COSTELLO DR STE 210
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4310
Practice Address - Country:US
Practice Address - Phone:540-247-8476
Practice Address - Fax:540-869-3524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty