Provider Demographics
NPI:1376282228
Name:LAWSON, RICKEY (PA-C)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:LAWSON
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:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:866-976-5941
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:866-976-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant