Provider Demographics
NPI:1235110875
Name:LAWRENCE, JEFFREY H (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:H
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 1:905 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-2921
Mailing Address - Country:US
Mailing Address - Phone:540-484-5585
Mailing Address - Fax:
Practice Address - Street 1:390 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1766
Practice Address - Country:US
Practice Address - Phone:540-484-4800
Practice Address - Fax:540-484-4862
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-840481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8918520Medicaid
970000127Medicare ID - Type Unspecified
VA8918520Medicaid
VA017858C18Medicare PIN