Provider Demographics
NPI:1295026631
Name:LAWRENCE, AMANDA N (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:N
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 1:16759 MAIN ST
Mailing Address - Street 2:STE. 201
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1232
Mailing Address - Country:US
Mailing Address - Phone:636-821-1661
Mailing Address - Fax:636-821-1665
Practice Address - Street 1:16759 MAIN ST
Practice Address - Street 2:STE. 201
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1232
Practice Address - Country:US
Practice Address - Phone:636-821-1661
Practice Address - Fax:636-821-1665
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011005771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant